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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target</title>
<author><name sortKey="Zhang, Haibo" sort="Zhang, Haibo" uniqKey="Zhang H" first="Haibo" last="Zhang">Haibo Zhang</name>
<affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.415502.7</institution-id>
<institution>The Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute,</institution>
<institution>St. Michaels Hospital,</institution>
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209 Victoria Street, Room 608, Toronto, ON M5B 1T8 Canada</nlm:aff>
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<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
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Guangzhou, China</nlm:aff>
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<institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id>
<institution>Interdepartmental Division of Critical Care Medicine; Departments of Anesthesia and Physiology,</institution>
<institution>University of Toronto,</institution>
</institution-wrap>
Toronto, Canada</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Penninger, Josef M" sort="Penninger, Josef M" uniqKey="Penninger J" first="Josef M." last="Penninger">Josef M. Penninger</name>
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<institution>Department of Medical Genetics, Life Science Institute,</institution>
<institution>University of British Columbia,</institution>
</institution-wrap>
Vancouver, BC Canada</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="GRID">grid.4299.6</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2169 3852</institution-id>
<institution>IMBA, Institute of Molecular Biotechnology,</institution>
<institution>Austrian Academy of Sciences,</institution>
</institution-wrap>
Vienna, Austria</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Li, Yimin" sort="Li, Yimin" uniqKey="Li Y" first="Yimin" last="Li">Yimin Li</name>
<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
</institution-wrap>
Guangzhou, China</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Zhong, Nanshan" sort="Zhong, Nanshan" uniqKey="Zhong N" first="Nanshan" last="Zhong">Nanshan Zhong</name>
<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
</institution-wrap>
Guangzhou, China</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Slutsky, Arthur S" sort="Slutsky, Arthur S" uniqKey="Slutsky A" first="Arthur S." last="Slutsky">Arthur S. Slutsky</name>
<affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.415502.7</institution-id>
<institution>The Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute,</institution>
<institution>St. Michaels Hospital,</institution>
</institution-wrap>
209 Victoria Street, Room 608, Toronto, ON M5B 1T8 Canada</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id>
<institution>Interdepartmental Division of Critical Care Medicine,</institution>
<institution>University of Toronto,</institution>
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Toronto, Canada</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
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Guangzhou, China</nlm:aff>
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<idno type="pmc">7079879</idno>
<idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7079879</idno>
<idno type="RBID">PMC:7079879</idno>
<idno type="doi">10.1007/s00134-020-05985-9</idno>
<date when="2020">2020</date>
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<sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target</title>
<author><name sortKey="Zhang, Haibo" sort="Zhang, Haibo" uniqKey="Zhang H" first="Haibo" last="Zhang">Haibo Zhang</name>
<affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.415502.7</institution-id>
<institution>The Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute,</institution>
<institution>St. Michaels Hospital,</institution>
</institution-wrap>
209 Victoria Street, Room 608, Toronto, ON M5B 1T8 Canada</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
</institution-wrap>
Guangzhou, China</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id>
<institution>Interdepartmental Division of Critical Care Medicine; Departments of Anesthesia and Physiology,</institution>
<institution>University of Toronto,</institution>
</institution-wrap>
Toronto, Canada</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Penninger, Josef M" sort="Penninger, Josef M" uniqKey="Penninger J" first="Josef M." last="Penninger">Josef M. Penninger</name>
<affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="GRID">grid.17091.3e</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2288 9830</institution-id>
<institution>Department of Medical Genetics, Life Science Institute,</institution>
<institution>University of British Columbia,</institution>
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Vancouver, BC Canada</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="GRID">grid.4299.6</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2169 3852</institution-id>
<institution>IMBA, Institute of Molecular Biotechnology,</institution>
<institution>Austrian Academy of Sciences,</institution>
</institution-wrap>
Vienna, Austria</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Li, Yimin" sort="Li, Yimin" uniqKey="Li Y" first="Yimin" last="Li">Yimin Li</name>
<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
</institution-wrap>
Guangzhou, China</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Zhong, Nanshan" sort="Zhong, Nanshan" uniqKey="Zhong N" first="Nanshan" last="Zhong">Nanshan Zhong</name>
<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
</institution-wrap>
Guangzhou, China</nlm:aff>
</affiliation>
</author>
<author><name sortKey="Slutsky, Arthur S" sort="Slutsky, Arthur S" uniqKey="Slutsky A" first="Arthur S." last="Slutsky">Arthur S. Slutsky</name>
<affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.415502.7</institution-id>
<institution>The Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute,</institution>
<institution>St. Michaels Hospital,</institution>
</institution-wrap>
209 Victoria Street, Room 608, Toronto, ON M5B 1T8 Canada</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id>
<institution>Interdepartmental Division of Critical Care Medicine,</institution>
<institution>University of Toronto,</institution>
</institution-wrap>
Toronto, Canada</nlm:aff>
</affiliation>
<affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
</institution-wrap>
Guangzhou, China</nlm:aff>
</affiliation>
</author>
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<series><title level="j">Intensive Care Medicine</title>
<idno type="ISSN">0342-4642</idno>
<idno type="eISSN">1432-1238</idno>
<imprint><date when="2020">2020</date>
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<pmc article-type="brief-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Intensive Care Med</journal-id>
<journal-id journal-id-type="iso-abbrev">Intensive Care Med</journal-id>
<journal-title-group><journal-title>Intensive Care Medicine</journal-title>
</journal-title-group>
<issn pub-type="ppub">0342-4642</issn>
<issn pub-type="epub">1432-1238</issn>
<publisher><publisher-name>Springer Berlin Heidelberg</publisher-name>
<publisher-loc>Berlin/Heidelberg</publisher-loc>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">32125455</article-id>
<article-id pub-id-type="pmc">7079879</article-id>
<article-id pub-id-type="publisher-id">5985</article-id>
<article-id pub-id-type="doi">10.1007/s00134-020-05985-9</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Understanding the Disease</subject>
</subj-group>
</article-categories>
<title-group><article-title>Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic target</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><contrib-id contrib-id-type="orcid">http://orcid.org/0000-0002-1714-3038</contrib-id>
<name><surname>Zhang</surname>
<given-names>Haibo</given-names>
</name>
<xref ref-type="aff" rid="Aff1">1</xref>
<xref ref-type="aff" rid="Aff3">3</xref>
<xref ref-type="aff" rid="Aff6">6</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Penninger</surname>
<given-names>Josef M.</given-names>
</name>
<xref ref-type="aff" rid="Aff4">4</xref>
<xref ref-type="aff" rid="Aff5">5</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Li</surname>
<given-names>Yimin</given-names>
</name>
<xref ref-type="aff" rid="Aff3">3</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Zhong</surname>
<given-names>Nanshan</given-names>
</name>
<xref ref-type="aff" rid="Aff3">3</xref>
</contrib>
<contrib contrib-type="author" corresp="yes"><name><surname>Slutsky</surname>
<given-names>Arthur S.</given-names>
</name>
<address><email>arthur.slutsky@unityhealth.to</email>
</address>
<xref ref-type="aff" rid="Aff1">1</xref>
<xref ref-type="aff" rid="Aff2">2</xref>
<xref ref-type="aff" rid="Aff3">3</xref>
</contrib>
<aff id="Aff1"><label>1</label>
<institution-wrap><institution-id institution-id-type="GRID">grid.415502.7</institution-id>
<institution>The Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute,</institution>
<institution>St. Michaels Hospital,</institution>
</institution-wrap>
209 Victoria Street, Room 608, Toronto, ON M5B 1T8 Canada</aff>
<aff id="Aff2"><label>2</label>
<institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id>
<institution>Interdepartmental Division of Critical Care Medicine,</institution>
<institution>University of Toronto,</institution>
</institution-wrap>
Toronto, Canada</aff>
<aff id="Aff3"><label>3</label>
<institution-wrap><institution-id institution-id-type="GRID">grid.470124.4</institution-id>
<institution>The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health,</institution>
<institution>The First Affiliated Hospital of Guangzhou Medical University,</institution>
</institution-wrap>
Guangzhou, China</aff>
<aff id="Aff4"><label>4</label>
<institution-wrap><institution-id institution-id-type="GRID">grid.17091.3e</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2288 9830</institution-id>
<institution>Department of Medical Genetics, Life Science Institute,</institution>
<institution>University of British Columbia,</institution>
</institution-wrap>
Vancouver, BC Canada</aff>
<aff id="Aff5"><label>5</label>
<institution-wrap><institution-id institution-id-type="GRID">grid.4299.6</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2169 3852</institution-id>
<institution>IMBA, Institute of Molecular Biotechnology,</institution>
<institution>Austrian Academy of Sciences,</institution>
</institution-wrap>
Vienna, Austria</aff>
<aff id="Aff6"><label>6</label>
<institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id>
<institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id>
<institution>Interdepartmental Division of Critical Care Medicine; Departments of Anesthesia and Physiology,</institution>
<institution>University of Toronto,</institution>
</institution-wrap>
Toronto, Canada</aff>
</contrib-group>
<pub-date pub-type="epub"><day>3</day>
<month>3</month>
<year>2020</year>
</pub-date>
<pub-date pub-type="pmc-release"><day>3</day>
<month>3</month>
<year>2020</year>
</pub-date>
<fpage>1</fpage>
<lpage>5</lpage>
<history><date date-type="received"><day>17</day>
<month>2</month>
<year>2020</year>
</date>
<date date-type="accepted"><day>20</day>
<month>2</month>
<year>2020</year>
</date>
</history>
<permissions><copyright-statement>© The Author(s) 2020</copyright-statement>
<license license-type="OpenAccess"><license-p><bold>Open Access</bold>
This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.To view a copy of this licence, visit <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/">http://creativecommons.org/licenses/by-nc/4.0/</ext-link>
.</license-p>
</license>
</permissions>
<funding-group><award-group><funding-source><institution-wrap><institution-id institution-id-type="FundRef">http://dx.doi.org/10.13039/501100000028</institution-id>
<institution>Institute of Circulatory and Respiratory Health</institution>
</institution-wrap>
</funding-source>
<award-id>FDN143285</award-id>
</award-group>
</funding-group>
<funding-group><award-group><funding-source><institution-wrap><institution-id institution-id-type="FundRef">http://dx.doi.org/10.13039/100000001</institution-id>
<institution>"Natural Science Foundation of China"</institution>
</institution-wrap>
</funding-source>
<award-id>81270125</award-id>
<award-id>81490530</award-id>
<award-id>2018GZR0201002</award-id>
</award-group>
</funding-group>
</article-meta>
</front>
<body><p id="Par1">A novel infectious disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was detected in Wuhan, China, in December 2019. The disease (COVID-19) spread rapidly, reaching epidemic proportions in China, and has been found in 27 other countries. As of February 27, 2020, over 82,000 cases of COVID-19 were reported, with > 2800 deaths. No specific therapeutics are available, and current management includes travel restrictions, patient isolation, and supportive medical care. There are a number of pharmaceuticals already being tested [<xref ref-type="bibr" rid="CR1">1</xref>
, <xref ref-type="bibr" rid="CR2">2</xref>
], but a better understanding of the underlying pathobiology is required. In this context, this article will briefly review the rationale for angiotensin-converting enzyme 2 (ACE2) receptor as a specific target.</p>
<sec id="Sec1"><title>SARS-CoV-2 and severe acute respiratory syndrome coronavirus (SARS-CoV) use ACE2 receptor to facilitate viral entry into target cells</title>
<p id="Par2">SARS-CoV-2 has been sequenced [<xref ref-type="bibr" rid="CR3">3</xref>
]. A phylogenetic analysis [<xref ref-type="bibr" rid="CR3">3</xref>
, <xref ref-type="bibr" rid="CR4">4</xref>
] found a bat origin for the SARS-CoV-2. There is a diversity of possible intermediate hosts for SARS-CoV-2, including pangolins, but not mice and rats [<xref ref-type="bibr" rid="CR5">5</xref>
].</p>
<p id="Par3">There are many similarities of SARS-CoV-2 with the original SARS-CoV. Using computer modeling, Xu et al. [<xref ref-type="bibr" rid="CR6">6</xref>
] found that the spike proteins of SARS-CoV-2 and SARS-CoV have almost identical 3-D structures in the receptor-binding domain that maintains van der Waals forces. SARS-CoV spike protein has a strong binding affinity to human ACE2, based on biochemical interaction studies and crystal structure analysis [<xref ref-type="bibr" rid="CR7">7</xref>
]. SARS-CoV-2 and SARS-CoV spike proteins share 76.5% identity in amino acid sequences [<xref ref-type="bibr" rid="CR6">6</xref>
] and, importantly, the SARS-CoV-2 and SARS-CoV spike proteins have a high degree of homology [<xref ref-type="bibr" rid="CR6">6</xref>
, <xref ref-type="bibr" rid="CR7">7</xref>
].</p>
<p id="Par4">Wan et al. [<xref ref-type="bibr" rid="CR4">4</xref>
] reported that residue 394 (glutamine) in the SARS-CoV-2 receptor-binding domain (RBD), corresponding to residue 479 in SARS-CoV, can be recognized by the critical lysine 31 on the human ACE2 receptor [<xref ref-type="bibr" rid="CR8">8</xref>
]. Further analysis even suggested that SARS-CoV-2 recognizes human ACE2 more efficiently than SARS-CoV increasing the ability of SARS-CoV-2 to transmit from person to person [<xref ref-type="bibr" rid="CR4">4</xref>
]. Thus, the SARS-CoV-2 spike protein was predicted to also have a strong binding affinity to human ACE2.</p>
<p id="Par5">This similarity with SARS-CoV is critical because ACE2 is a functional SARS-CoV receptor in vitro [<xref ref-type="bibr" rid="CR9">9</xref>
] and in vivo [<xref ref-type="bibr" rid="CR10">10</xref>
]. It is required for host cell entry and subsequent viral replication. Overexpression of human ACE2 enhanced disease severity in a mouse model of SARS-CoV infection, demonstrating that viral entry into cells is a critical step [<xref ref-type="bibr" rid="CR11">11</xref>
]; injecting SARS-CoV spike into mice worsened lung injury. Critically, this injury was attenuated by blocking the renin-angiotensin pathway and depended on ACE2 expression [<xref ref-type="bibr" rid="CR12">12</xref>
]. Thus, for SARS-CoV pathogenesis, ACE2 is not only the entry receptor of the virus but also protects from lung injury. We therefore previously suggested that in contrast to most other coronaviruses, SARS-CoV became highly lethal because the virus deregulates a lung protective pathway [<xref ref-type="bibr" rid="CR10">10</xref>
, <xref ref-type="bibr" rid="CR12">12</xref>
].</p>
<p id="Par6">Zhou et al. [<xref ref-type="bibr" rid="CR13">13</xref>
] demonstrated that overexpressing ACE2 from different species in HeLa cells with human ACE2, pig ACE2, civet ACE2 (but not mouse ACE2) allowed SARS-CoV-2 infection and replication, thereby directly showing that SARS-CoV-2 uses ACE2 as a cellular entry receptor. They further demonstrated that SARS-CoV-2 does not use other coronavirus receptors such as aminopeptidase N and dipeptidyl peptidase 4 [<xref ref-type="bibr" rid="CR13">13</xref>
]. In summary, the SARS-CoV-2 spike protein directly binds with the host cell surface ACE2 receptor facilitating virus entry and replication.</p>
</sec>
<sec id="Sec2"><title>Enrichment distribution of ACE2 receptor in human alveolar epithelial cells (AEC)</title>
<p id="Par7">A key question is why the lung appears to be the most vulnerable target organ. One reason is that the vast surface area of the lung makes the lung highly susceptible to inhaled viruses, but there is also a biological factor. Using normal lung tissue from eight adult donors, Zhao et al. [<xref ref-type="bibr" rid="CR14">14</xref>
] demonstrated that 83% of ACE2-expressing cells were alveolar epithelial type II cells (AECII), suggesting that these cells can serve as a reservoir for viral invasion. In addition, gene ontology enrichment analysis showed that the ACE2-expressing AECII have high levels of multiple viral process-related genes, including regulatory genes for viral processes, viral life cycle, viral assembly, and viral genome replication [<xref ref-type="bibr" rid="CR14">14</xref>
], suggesting that the ACE2-expressing AECII facilitate coronaviral replication in the lung.</p>
<p id="Par8">Expression of the ACE2 receptor is also found in many extrapulmonary tissues including heart, kidney, endothelium, and intestine [<xref ref-type="bibr" rid="CR15">15</xref>
–<xref ref-type="bibr" rid="CR19">19</xref>
]. Importantly, ACE2 is highly expressed on the luminal surface of intestinal epithelial cells, functioning as a co-receptor for nutrient uptake, in particular for amino acid resorption from food [<xref ref-type="bibr" rid="CR20">20</xref>
]. We therefore predict that the intestine might also be a major entry site for SARS-CoV-2 and that the infection might have been initiated by eating food from the Wuhan market, the putative site of the outbreak. Whether SARS-CoV-2 can indeed infect the human gut epithelium has important implications for fecal–oral transmission and containment of viral spread. ACE2 tissue distribution in other organs could explain the multi-organ dysfunction observed in patients [<xref ref-type="bibr" rid="CR21">21</xref>
–<xref ref-type="bibr" rid="CR23">23</xref>
]. Of note, however, according to the Centers for Disease Control and Prevention [<xref ref-type="bibr" rid="CR24">24</xref>
], whether a person can get COVID-19 by touching surfaces or objects that have virus on them and then touching mucus membranes is yet to be confirmed.</p>
</sec>
<sec id="Sec3"><title>Potential approaches to address ACE2-mediated COVID-19</title>
<p id="Par9">There are several potential therapeutic approaches (Fig. <xref rid="Fig1" ref-type="fig">1</xref>
).<list list-type="order"><list-item><p id="Par10"><italic>Spike protein-based vaccine.</italic>
</p>
<p id="Par11">Development of a spike1 subunit protein-based vaccine may rely on the fact that ACE2 is the SARS-CoV-2 receptor. Cell lines that facilitate viral replication in the presence of ACE2 may be most efficient in large-scale vaccine production.</p>
</list-item>
<list-item><p id="Par12"><italic>Inhibition of transmembrane protease serine 2 (TMPRSS2) activity.</italic>
</p>
<p id="Par13">Hoffman et al. [<xref ref-type="bibr" rid="CR25">25</xref>
] recently demonstrated that initial spike protein priming by transmembrane protease serine 2 (TMPRSS2) is essential for entry and viral spread of SARS-CoV-2 through interaction with the ACE2 receptor [<xref ref-type="bibr" rid="CR26">26</xref>
, <xref ref-type="bibr" rid="CR27">27</xref>
]. The serine protease inhibitor camostat mesylate, approved in Japan to treat unrelated diseases, has been shown to block TMPRSS2 activity [<xref ref-type="bibr" rid="CR28">28</xref>
, <xref ref-type="bibr" rid="CR29">29</xref>
] and is thus an interesting candidate.</p>
</list-item>
<list-item><p id="Par14"><italic>Blocking ACE2 receptor.</italic>
</p>
<p id="Par15">The interaction sites between ACE2 and SARS-CoV have been identified at the atomic level and from studies to date should also hold true for interactions between ACE2 and SARS-CoV-2. Thus, one could target this interaction site with antibodies or small molecules.</p>
</list-item>
<list-item><p id="Par16"><italic>Delivering excessive soluble form of ACE2.</italic>
</p>
<p id="Par17">Kuba et al. [<xref ref-type="bibr" rid="CR10">10</xref>
] demonstrated in mice that SARS-CoV downregulates ACE2 protein (but not ACE) by binding its spike protein, contributing to severe lung injury. This suggests that excessive ACE2 may competitively bind with SARS-CoV-2 not only to neutralize the virus but also rescue cellular ACE2 activity which negatively regulates the renin-angiotensin system (RAS) to protect the lung from injury [<xref ref-type="bibr" rid="CR12">12</xref>
, <xref ref-type="bibr" rid="CR30">30</xref>
]. Indeed, enhanced ACE activity and decreased ACE2 availability contribute to lung injury during acid- and ventilator-induced lung injury [<xref ref-type="bibr" rid="CR12">12</xref>
, <xref ref-type="bibr" rid="CR31">31</xref>
, <xref ref-type="bibr" rid="CR32">32</xref>
]. Thus, treatment with a soluble form of ACE2 itself may exert dual functions: (1) slow viral entry into cells and hence viral spread [<xref ref-type="bibr" rid="CR7">7</xref>
, <xref ref-type="bibr" rid="CR9">9</xref>
] and (2) protect the lung from injury [<xref ref-type="bibr" rid="CR10">10</xref>
, <xref ref-type="bibr" rid="CR12">12</xref>
, <xref ref-type="bibr" rid="CR31">31</xref>
, <xref ref-type="bibr" rid="CR32">32</xref>
].</p>
</list-item>
</list>
Notably, a recombinant human ACE2 (rhACE2; APN01, GSK2586881) has been found to be safe, with no negative hemodynamic effects in healthy volunteers and in a small cohort of patients with ARDS [<xref ref-type="bibr" rid="CR33">33</xref>
–<xref ref-type="bibr" rid="CR35">35</xref>
]. The administration of APN01 rapidly decreased levels of its proteolytic target peptide angiotensin II, with a trend to lower plasma IL-6 concentrations. Our previous work on SARS-CoV pathogenesis makes ACE2 a rational and scientifically validated therapeutic target for the current COVID-19 pandemic. The availability of recombinant ACE2 was the impetus to assemble a multinational team of intensivists, scientists, and biotech to rapidly initiate a pilot trial of rhACE2 in patients with severe COVID-19 (Clinicaltrials.gov #NCT04287686).<fig id="Fig1"><label>Fig. 1</label>
<caption><p>Potential approaches to address ACE2-mediated COVID-19 following SARS-CoV-2 infection. The finding that SARS-CoV-2 and SARS-CoV use the ACE2 receptor for cell entry has important implications for understanding SARS-CoV-2 transmissibility and pathogenesis. SARS-CoV and likely SARS-CoV-2 lead to downregulation of the ACE2 receptor, but not ACE, through binding of the spike protein with ACE2. This leads to viral entry and replication, as well as severe lung injury. Potential therapeutic approaches include a SARS-CoV-2 spike protein-based vaccine; a transmembrane protease serine 2 (TMPRSS2) inhibitor to block the priming of the spike protein; blocking the surface ACE2 receptor by using anti-ACE2 antibody or peptides; and a soluble form of ACE2 which should slow viral entry into cells through competitively binding with SARS-CoV-2 and hence decrease viral spread as well as protecting the lung from injury through its unique enzymatic function. MasR—mitochondrial assembly receptor, AT1R—Ang II type 1 receptor</p>
</caption>
<graphic xlink:href="134_2020_5985_Fig1_HTML" id="MO1"></graphic>
</fig>
</p>
</sec>
</body>
<back><fn-group><fn><p><bold>Publisher's Note</bold>
</p>
<p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p>
</fn>
</fn-group>
<ack><title>Acknowledgements</title>
<p>This study was funded in part by the following agencies; the Canadian Institutes of Health Research FDN143285; National Nature Science Foundation of China (81270125, 81490530, 2018GZR0201002); and Clinical Innovation Research Program of Guangzhou Regenerative Medicine and Health Guangdong Laboratory (2018GZR0201002).</p>
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<notes notes-type="ethics"><title>Compliance with ethical standards</title>
<notes notes-type="COI-statement"><title>Conflicts of interest</title>
<p id="Par18">Josef Penninger is the founder and a shareholder of Apeiron, the company that makes rhACE2. Arthur Slutsky has been a paid consultant for Apeiron. No other conflicts of interested have been reported.</p>
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