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Immunoreactivity of the SARS-CoV-2 entry proteins ACE-2 and TMPRSS-2 in murine models of hormonal manipulation, ageing, and cardiac injury

Abstract

Previous work indicates that SARS-CoV-2 virus entry proteins angiotensin-converting enzyme 2 (ACE-2) and the cell surface transmembrane protease serine 2 (TMPRSS-2) are regulated by sex hormones. However, clinical studies addressing this association have yielded conflicting results. We sought to analyze the impact of sex hormones, age, and cardiovascular disease on ACE-2 and TMPRSS-2 expression in different mouse models. ACE-2 and TMPRSS-2 expression was analyzed by immunostaining in a variety of tissues obtained from FVB/N mice undergoing either gonadectomy or sham-surgery and being subjected to ischemia–reperfusion injury or transverse aortic constriction surgery. In lung tissues sex did not have a significant impact on the expression of ACE-2 and TMPRSS-2. On the contrary, following myocardial injury, female sex was associated to a lower expression of ACE-2 at the level of the kidney tubules. In addition, after myocardial injury, a significant correlation between younger age and higher expression of both ACE-2 and TMPRSS-2 was observed for lung alveoli and bronchioli, kidney tubules, and liver sinusoids. Our experimental data indicate that gonadal hormones and biological sex do not alter ACE-2 and TMPRSS-2 expression in the respiratory tract in mice, independent of disease state. Thus, sex differences in ACE-2 and TMPRSS-2 protein expression observed in mice may not explain the higher disease burden of COVID-19 among men.

Introduction

As of June 2021, the coronavirus disease (COVID)-19 pandemic has caused more than 175 Mio infections and 3.7 Mio deaths worldwide. Pre-existing cardiovascular disease (CVD) has been identified as predominant risk factor for a poor prognosis in COVID-19 patients1,2,3. Suggested mechanisms accounting for this association involve the SARS-CoV-2 entry proteins angiotensin-converting enzyme 2 (ACE-2) and transmembrane protease serine 2 (TMPRSS-2). Emerging data support the hypothesis that the expression of these entry proteins is increased in patients with CVD, particularly in cardiomyocytes4. As such, recent results demonstrated that patients with non-ischemic dilated cardiomyopathy, hypertrophic cardiomyopathy, and aortic stenosis exhibit increased expression of ACE-25,6 and that TMPRSS-2 expression increases with age and in males7, all of which have been associated with adverse outcomes in COVID-193,8,9. Animal models of gonadectomy showing that estrogen and testosterone exert opposite effects on myocardial ACE-2 expression further support a sexual dimorphism in SARS-CoV-2 entry protein regulation10. Despite this, clinical studies addressing the role of sex as well as sex hormones and regulation of ACE-2 and TMPRSS-2 in COVID-19 patients are scarce and the few studies available have yielded conflicting results. While initial reports identified a link between the androgen-mediated phenotype of androgenetic alopecia and COVID-19 disease severity11,12 as well as a reduced COVID-19 incidence or disease burden in men receiving anti-androgenic treatment13,14,15, more recent data have refuted this association16,17,18,19. Also, new results point towards a bivalent role of testosterone in COVID-19 as lower serum testosterone levels predicted poor prognosis and mortality in critically ill men infected with SARS-CoV-220,21. In women, a study from Wuhan, China, demonstrated that higher anti-Müllerian hormone or estradiol levels were associated with a mild COVID-19 disease course in 78 female patients22, and a retrospective analysis of 68′466 electronic health records reported a reduction of COVID-19 fatality risk by 50% in 439 postmenopausal women receiving hormone replacement (HR) therapy23. Conversely, preliminary data from the UK-based COVID Symptom Study indicate that HR therapy was positively associated with COVID-19 severity24, and no increased risk of COVID-19 related mortality was seen in women with gynecologic cancers25. Finally, in vitro as well as clinical data showed a reduction of SARS-CoV-2 infection by selective estrogen receptor modulators, but not by agonists/antagonists of estrogen, androgens, or progesterone26,27.

Given the paucity of data on ACE-2 and TMPRSS-2 protein expression and their interaction with comorbid health conditions and age, we sought to analyze whether sex hormones, age, and CVD impact ACE-2 and TMPRSS-2 expression in murine models.

Method

Study objectives

The ACE-2 receptor is expressed on different types of cells and tissues including human airway epithelia, lung parenchyma, vascular endothelia, renal tubulointerstitial and glomerular cells, central nervous system cells, and small intestinal cells. However, SARS-CoV-2 primarily infects airway epithelial cells. Therefore, the primary objective of our study was to assess whether ACE-2 and TMPRSS-2 expression in lung tissue is regulated by sex, sex hormones, and age at baseline and following myocardial injury. Secondary aims comprised (1) the assessment of ACE-2 and TMPRSS-2 expression in renal and hepatic tissues, and (2) the evaluation of the impact of chronic pressure overload and female reproductive history on ACE-2 and TMPRSS-2 expression in lung, kidney, and liver tissues.

Mouse models

ACE-2 and TMPRSS-2 expression was analyzed in female and male FVB/N mice (Janvier Labs, France) at different ages (4 months [young], 12 months [middle-aged], and 20–22 months [aged]), with either intact or different hormonal status, as well as different CVD states. All animals were housed in individually ventilated cages with ad libitum access to water and food, and under specific pathogen-free conditions. To test our hypothesis, experimental models of acute myocardial injury (ischemia-reperfusion model) and chronic pressure overload of the left ventricle (LV) as well as evaluation of female mice reproductive history were employed.

Acute myocardial injury model

Before surgery, mice were randomly assigned to either gonadectomy (Gx) or sham-surgery at the age of 4 weeks, before reaching sexual maturity. Following gonadectomy, mice were randomized to different experimental groups and 90-days sex HR pellets (in Gx + HR mice) or corresponding vehicle controls (in Gx mice) were implanted. For this purpose, either 0.18 mg of 17β-estradiol or 12.5 mg of testosterone pellets (Innovative Research of America, Sarasota, FL, U.S.) were implanted subcutaneously via a 3 mm incision on the dorsal neck. The pellets were renewed every 90-days under isoflurane anesthesia until final assessment to ensure stable long-term hormone treatment. Subgroups of young and aged mice underwent ischemia–reperfusion injury by inducing transient (30 min) ligation of the left anterior descending artery. Organs were harvested after 24 h of reperfusion. A detailed description of the surgical procedure is reported in the Supplementary Information.

Chronic pressure overload model

Young FVB/N mice with intact hormonal status underwent transverse aortic constriction (TAC) or sham surgery to induce persistent pressure overload of the left LV over a total observational time of 28 days. A detailed description of the surgical procedure is reported in the Supplementary Information.

The development of pressure overload of the LV was verified by cardiovascular magnetic resonance imaging on a Bruker BioSpec 70/30 USR magnetic resonance scanner in all mice (data available upon request).

Female reproductive history

To assess the potential effect of multiple pregnancies on ACE-2 and TMPRSS-2 expression, tissues of female FVB/N breeders [multiparous] and non-breeders [nulliparous] at the age of 12 months were evaluated.

After harvesting, organs were stored at 4 °C in 4% buffered formaldehyde until further analysis. Blood samples were obtained by cardiac puncture and centrifuged at 10,000g for 10 min. The resulting serum samples were snap frozen and stored at − 80 °C until further analysis. All experimental protocols were reviewed and approved by the Commission on Animal Experimentation of the Canton of Zurich and the Cantonal Veterinary Office (link: Application and authorization (admin.ch); license number ZH207/16 and ZH079/18), were carried out in accordance with relevant guidelines and regulations, and reported in accordance with ARRIVE guidelines.

Serum and tissue analysis

Serum sex hormone and soluble ACE-2 (sACE-2) levels were measured using mouse/rat ELISA assays (Calbiotech Inc., El Cajon, CA, U.S and Cloud-Clone Corp., Katy, TX, U.S, respectively) according to the manufacturer’s recommendation. Immunohistochemical stains were performed on formalin-fixed and paraffin embedded tissue using a Bond RX Platform. Immunostainings were performed with established antibodies against the following proteins and visualized using the Bond™ Polymer Refine Detection kit (Leica Biosystems Inc., Buffalo Grove, IL, U.S.): ACE-2; 1:500 dilution (Abcam, #239924) and TMPRSS-2, 1:2,000 dilution (Abcam, #92323). Incubation times were 30 min, respectively, at room temperature. The level of immunoreactivity of ACE-2 and TMPRSS-2 were scored semi-quantitatively (0 = negative; 1 = low; 2 = moderate; 3 = high, Fig. 1A,B). Only membranous staining was evaluated. Additionally, a pattern-based scoring approach was used to evaluate expression levels on liver sinusoids (0 = negative; 1 = portal sinusoids only; 2 = extension to periportal area; 3 = porto-portal/septal pattern). At hepatic level, only the expression of ACE-2 was evaluated since tissue sections were uninterpretable for TMPRSS-2 assessment.

Figure 1
figure 1

Scoring examples of ACE-2 (upper row) and TMPRSS-2 (lower row) in lung alveoli (A) and lung bronchioli (B). From left to right: Score = 1 (low immunoreactivity), score = 2 (moderate immunoreactivity), score = 3 (high immunoreactivity). Only membranous staining was evaluated. ACE-2, angiotensin-converting enzyme 2; TMPRSS-2, transmembrane protease serine 2.

Statistical analysis

Data are presented as median (interquartile range) for immunostaining and mean ± standard error of the mean (SEM) for serum analyses. For continuous variables prior to analyses, basic assumptions including normal distribution and homogeneity of variances were checked. Unpaired Student’s t-test, Mann–Whitney test, analysis of variance (ANOVA), or Kruskal–Wallis test were used for group comparisons of serum samples. Mann–Whitney test was performed to compare ACE-2 and TMPRSS-2 immunoreactivity between breeders and non-breeders. Ordinal logistic regression was used to evaluate the impact of age, sex, and type of hormonal status on the different levels of expression of ACE-2 and TMPRSS-2 in the different tissues. Statistical tests were two-sided, and significance was set at p < 0.05. Statistical analyses were performed with IBM SPSS statistics v25.0 and R software28.

Results

ACE-2 and TMPRSS-2 expression were assessed in different organs and tissues including lung (alveoli and bronchioli), kidney tubules, and liver sinusoids (Tables 1, 2, 3).

Table 1 Impact of age, sex and hormone deprivation/replacement status on ACE-2 and TMPRSS-2 expression at baseline condition.
Table 2 Impact of age, sex and hormone deprivation/replacement status on ACE-2 and TMPRSS-2 expression after acute myocardial injury.
Table 3 Impact of female reproductive history on ACE-2 and TMPRSS-2 expression.

Impact of age, sex, and myocardial injury on ACE-2 and TMPRSS-2 expression in lung tissue

In lung alveoli, sex was not associated with the expression level of ACE-2 and TMPRSS-2 under baseline conditions (p = 0.450 and p = 0.790, respectively) (Fig. 2A,B) and following ischemia–reperfusion injury (p = 0.300 and p = 0.924, respectively) (Fig. 3A,B).

Figure 2
figure 2

ACE-2 and TMPRSS-2 immunoreactivity in lung alveoli in murine models of ageing and hormonal manipulation. The violin plots provide information on the full data distribution. The horizontal black line indicates the median of the kernel density plot. (A) ACE-2 immunoreactivity in young (left panel) and aged (right panel) control animals, gonadectomized animals, and gonadectomized animals receiving long-term hormone replacement. (B) TMPRSS-2 immunoreactivity in young (left panel) and aged (right panel) control animals, gonadectomized animals, and gonadectomized animals receiving long-term hormone replacement. Ordinal logistic regression was performed to test the association between the level of expression of ACE-2 and TMPRSS-2 with age, sex, and hormonal status. The resulting p-values are reported in the box. ACE-2, angiotensin-converting enzyme 2; Gx, gonadectomy; HR, hormone replacement; TMPRSS-2, transmembrane protease serine 2.

Figure 3
figure 3

ACE-2 and TMPRSS-2 immunoreactivity in lung alveoli in a murine model of ageing, hormonal manipulation, and myocardial injury. The violin plots provide information on the full data distribution. The horizontal black line indicates the median of the kernel density plot. (A) ACE-2 immunoreactivity in young (left panel) and aged (right panel) control animals, gonadectomized animals, and gonadectomized animals receiving long-term hormone replacement following ischemia-reperfusion injury. (B) TMPRSS-2 immunoreactivity in young (left panel) and aged (right panel) control animals, gonadectomized animals and gonadectomized animals receiving long-term hormone replacement following ischemia-reperfusion injury. (C) Soluble angiotensin-converting enzyme (sACE-2) serum levels in young mice at baseline and following ischemia/reperfusion injury. Ordinal logistic regression was performed to test the association between the level of expression of ACE-2 and TMPRSS-2 with age, sex, and hormonal status. The resulting p-values are reported in the box. Unpaired Student’s t-test was applied for comparison of sACE-2 (only the significant p-value is reported). ACE-2, angiotensin-converting enzyme 2; Gx, gonadectomy; HR, hormone replacement; sACE-2, soluble angiotensin-converting enzyme; TMPRSS-2, transmembrane protease serine 2.

Age did not have a significant impact on the level of ACE-2 expression in the lung alveoli at baseline condition (p = 0.225) (Fig. 2A). On the contrary, higher alveolar ACE-2 expression was associated with younger age following myocardial injury (p = 0.044) (Fig. 3A). Increasing age was associated with a lower expression of pulmonary TMPRSS-2 expression under baseline conditions (p = 0.001) and following myocardial injury (p < 0.001) (Figs. 2B and 3B). Similar observations were found for lung bronchioli (Tables 1 and 2).

Circulating sACE-2 levels were significantly higher in females following ischemia–reperfusion injury as compared to males (p = 0.010, Fig. 3C), while this sex difference was not observed under baseline conditions (p = 0.520).

Impact of age, sex, and myocardial injury on ACE-2 and TMPRSS-2 expression in kidney, and hepatic tissues

In the kidney tubules, female sex was associated to a lower level of ACE-2 and TMPRSS-2 expression as compared to males following myocardial injury (p = 0.006) and at baseline condition (p = 0.014), respectively. In addition, following myocardial injury, Gx and Gx + HR therapy were associated with a lower extent of ACE-2 expression in the liver sinusoids as compared to the control group (p = 0.039 and p = 0.014, respectively). No additional age, sex, and hormonal status differences in the expression pattern of ACE-2 and TMPRSS-2 were observed in the remaining tissues and experimental groups (Tables 1 and 2).

Younger age was associated with a higher level of ACE-2 expression in kidney tubules and liver sinusoids at baseline (p = 0.004 and p < 0.001, respectively, Table 1) and following myocardial injury (p = 0.009 and p < 0001, respectively, Table 2). Similarly, following myocardial injury, a higher level of expression of TMPRSS-2 in the kidney tubules was correlated with younger age (p = 0.005, Table 2).

Impact of sex and chronic pressure overload on ACE-2 and TMPRSS-2 expression in lung, kidney, and hepatic tissues

The distribution of ACE-2 and TMPRSS-2 expression level in female and male mice who underwent TAC surgery is reported in the Supplementary Information (Supplemental Table 1 and Supplemental Table 2). Statistical comparisons were not performed due to the small number of animals per group.

Impact of female reproductive history on ACE-2 and TMPRSS-2 expression

Female reproductive history did not impact pulmonary expression levels of ACE-2 and TMPRSS-2 as no difference in ACE-2 or TMPRSS-2 expression was observed in multiparous versus nulliparous mice (12 months old; Fig. 4A,B; Table 3). Multiparous mice had significantly higher progesterone levels as compared to nulliparous mice (p = 0.01, Fig. 4C) which is consistent with an increase in progesterone during pregnancy and shortly thereafter.

Figure 4
figure 4

ACE-2 and TMPRSS-2 immunoreactivity in lung alveoli in murine models of pregnancy. The violin plots (A and B) provide information on the full data distribution. The horizontal black line indicates the median of the kernel density plot. (A) ACE-2 immunoreactivity in lung alveoli of 12 months-old multiparous and nulliparous mice. (B) TMPRSS-2 immunoreactivity in lung alveoli of 12 months-old multiparous and nulliparous mice. (C) Serum progesterone level in both groups. Mann–Whitney test was performed to compare the median of the tissue expression of ACE-2 and TMPRSS-2 between nulliparous and multiparous. Unpaired Student’s t-test was applied for comparison of progesterone levels. Only significant p-values are reported (more details in Table 3). ACE-2, angiotensin-converting enzyme 2; TMPRSS-2, transmembrane protease serine 2.

Discussion

Impact of sex on lung expression of ACE-2 and TMPRSS-2

Our experimental data indicate that gonadal hormones and biological sex do not alter the expression of membrane-bound ACE-2 and TMPRSS-2 in the respiratory tract in mice, independent of disease state. Previous data on ACE-2 and TMPRSS-2 expression in lung tissue have yielded conflicting results. Indeed, studies in both human and mouse tissue have reported higher, lower or similar ACE-2 expression in males as compared to females29,30,31,32 as well as an upregulation (public genomics data) or downregulation (mRNA levels in bronchial epithelial cells) of ACE-2 by estrogen33,34. Similarly, while a recent mRNA sequencing study reports a higher TMPRSS-2 expression in men35, previous studies did not detect such sex differences across different tissues31,36. Species differences, difficulties in precisely measuring membrane-bound ACE-2 expression and activity at the tissue level, confounding variables such as smoking37 and obesity38 as well as counter-regulatory effects of estrogens on the renin angiotensin system may have caused the high variability of available data.

Impact of female reproductive history on ACE-2 and TMPRSS-2 expression

Several studies have reported the anti-inflammatory properties of progesterone, including inhibition of neutrophil degranulation and suppression of pro-inflammatory cytokine production39. As such, a recent pilot study has shown that subcutaneous administration of progesterone improved clinical status in 42 critically ill men infected with SARS-CoV-239. However, the actions of progesterone on ACE-2 and TMPRSS-2 expression are currently unknown. Multiparous 12-months old mice in our study had significantly higher levels of progesterone than nulliparous mice while estrogen levels were low in both groups. Both ACE-2 and TMPRSS-2 expression did not differ between these two groups across various tissues. Therefore, our data support the hypothesis that the immunomodulatory actions of progesterone40 rather than an effect of progesterone on SARS-CoV-2 receptor proteins may play a role in modulating COVID-19 disease course. Nevertheless, further studies addressing COVID-19 morbidity and mortality during pregnancy are needed given that the placenta and the uterus are important sources of ACE-2.

Impact of sex on ACE-2 and TMPRSS-2 expression in non-cardiac tissues

Pre-existing heart disease has been identified as a strong and independent predictor of adverse outcomes following SARS-CoV-2 infection1. Moreover, new cardiac complications are present in up to 12% of hospitalized COVID-19 patients41. Previous data suggests that myocardial ACE-2 expression is upregulated in cardiac dysfunction42 with two studies reporting more pronounced alterations in males43,44. However, the impact of myocardial disease on ACE-2 expression in non-cardiac tissue is currently unknown.

In our study, no sex difference in ACE-2 expression was observed in the experimental groups or organs evaluated with the exception of kidney tubules. This finding is consistent with the reports of two previous studies showing higher ACE-2 activity in male mouse kidneys as compared to females45,46.

Overall, the interaction between male sex and CVD in predicting COVID-19 mortality seems independent of sex differences in ACE-2 expression levels. Differences in immune status associated with cardiovascular comorbidities offer potential alternative explanations for the bias towards male deaths in COVID-19.

Impact of age on ACE-2 and TMPRSS-2 expression

Age is another risk factor for both morbidity and mortality in COVID-19 patients, with children being mostly resistant to the effects of the SARS-CoV-2 virus. In our study, higher pulmonary TMPRSS-2 expression was associated with younger age at baseline condition and following myocardial injury and reperfusion. Similarly, higher TMPRSS-2 expression in kidney tubules was associated with younger age following myocardial injury. Age-dependent changes for alveolar ACE-2 were observed only following myocardial injury. These data contrast with the findings of higher ACE-2 and TMPRSS-2 expression with age reported in a recent study35. Species differences as well as differences between protein and gene expression levels may account for these inconsistent findings. Of note, other authors described higher sACE-2 serum levels in children as compared to adults47 as well as a decreasing tubulointerstitial ACE-2 expression with age48.

Conclusion

Taken together, sex differences in the expression of ACE-2 and TMPRSS-2 observed in mice may not explain the higher disease burden of COVID-19 among men and contrast with recently reported sex differences on the gene expression level in humans35. Further research into the applicability and translational value of preclinical models to study underlying disease mechanisms of COVID-19 is needed.

Abbreviations

ACE-2:

Angiotensin-converting enzyme 2

ANOVA:

Analysis of variance

COVID-19:

Coronavirus disease

CVD:

Cardiovascular disease

Gx:

Gonadectomy

HR:

Hormone replacement

LV:

Left ventricle

sACE-2:

Soluble ACE-2

TAC:

Transverse aortic constriction

TMPRSS-2:

Transmembrane protease serine 2

References

  1. Bae, S., Kim, S. R., Kim, M. N., Shim, W. J. & Park, S. M. Impact of cardiovascular disease and risk factors on fatal outcomes in patients with COVID-19 according to age: A systematic review and meta-analysis. Heart 107, 373–380. https://doi.org/10.1136/heartjnl-2020-317901 (2021).

    CAS  Article  PubMed  Google Scholar 

  2. Harrison, S. L., Buckley, B. J. R., Rivera-Caravaca, J. M., Zhang, J. & Lip, G. Y. H. Cardiovascular risk factors, cardiovascular disease, and COVID-19: An umbrella review of systematic reviews. Eur. Heart J. Qual. Care Clin. Outcomes 7, 330–339. https://doi.org/10.1093/ehjqcco/qcab029 (2021).

    Article  PubMed  Google Scholar 

  3. Williamson, E. J. et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 584, 430–436. https://doi.org/10.1038/s41586-020-2521-4 (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. Chung, M. K. et al. COVID-19 and cardiovascular disease: From bench to bedside. Circ. Res. 128, 1214–1236. https://doi.org/10.1161/CIRCRESAHA.121.317997 (2021).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. Nicin, L. et al. Cell type-specific expression of the putative SARS-CoV-2 receptor ACE2 in human hearts. Eur. Heart J. 41, 1804–1806. https://doi.org/10.1093/eurheartj/ehaa311 (2020).

    CAS  Article  PubMed  Google Scholar 

  6. Tucker, N. R. et al. Myocyte-specific upregulation of ACE2 in cardiovascular disease: Implications for SARS-CoV-2-mediated myocarditis. Circulation 142, 708–710. https://doi.org/10.1161/CIRCULATIONAHA.120.047911 (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. Muus, C.et al. Integrated analyses of single-cell atlases reveal age, gender, and smoking status associations with cell type-specific expression of mediators of SARS-CoV-2 viral entry and highlights inflammatory programs in putative target cells. BioRxiv. https://doi.org/10.1101/2020.04.19.049254 (2020).

    Article  Google Scholar 

  8. Gebhard, C., Regitz-Zagrosek, V., Neuhauser, H. K., Morgan, R. & Klein, S. L. Impact of sex and gender on COVID-19 outcomes in Europe. Biol. Sex Differ. 11, 29. https://doi.org/10.1186/s13293-020-00304-9 (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  9. Nguyen, N. T. et al. Male gender is a predictor of higher mortality in hospitalized adults with COVID-19. PLoS ONE 16, e0254066. https://doi.org/10.1371/journal.pone.0254066 (2021).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  10. Fischer, M., Baessler, A. & Schunkert, H. Renin angiotensin system and gender differences in the cardiovascular system. Cardiovasc. Res. 53, 672–677. https://doi.org/10.1016/s0008-6363(01)00479-5 (2002).

    CAS  Article  PubMed  Google Scholar 

  11. Goren, A. et al. A preliminary observation: Male pattern hair loss among hospitalized COVID-19 patients in Spain—A potential clue to the role of androgens in COVID-19 severity. J. Cosmet. Dermatol. 19, 1545–1547. https://doi.org/10.1111/jocd.13443 (2020).

    Article  PubMed  Google Scholar 

  12. Wambier, C. G. et al. Androgenetic alopecia present in the majority of patients hospitalized with COVID-19: The “Gabrin sign”. J. Am. Acad. Dermatol. 83, 680–682. https://doi.org/10.1016/j.jaad.2020.05.079 (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Montopoli, M. et al. Androgen-deprivation therapies for prostate cancer and risk of infection by SARS-CoV-2: A population-based study (N = 4532). Ann. Oncol. 31, 1040–1045. https://doi.org/10.1016/j.annonc.2020.04.479 (2020).

    CAS  Article  PubMed  Google Scholar 

  14. Goren, A. et al. Anti-androgens may protect against severe COVID-19 outcomes: Results from a prospective cohort study of 77 hospitalized men. J. Eur. Acad. Dermatol. Venereol. https://doi.org/10.1111/jdv.16953 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  15. McCoy, J. et al. 5-alpha-reductase inhibitors are associated with reduced frequency of COVID-19 symptoms in males with androgenetic alopecia. J. Eur. Acad. Dermatol. Venereol. https://doi.org/10.1111/jdv.17021 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kwon, D. et al. Androgen deprivation therapy and risk of SARS-CoV-2 infection in men with prostate cancer: A University of California (UC) Health System registry study. J. Clin. Oncol. 39, 37 (2021).

    Article  Google Scholar 

  17. Tucker, M. D. et al. Severe-COVID-19 and mortality among patients (pts) with prostate cancer (PCa) receiving androgen deprivation therapy (ADT). J. Clin. Oncol. 39, 39. https://doi.org/10.1200/JCO.2021.39.6_suppl.39 (2021).

    Article  Google Scholar 

  18. Patel, V. G. et al. The role of androgen deprivation therapy on the clinical course of COVID-19 infection in men with prostate cancer. J. Clin. Oncol. 39, 41. https://doi.org/10.1200/JCO.2021.39.6_suppl.41 (2021).

    Article  Google Scholar 

  19. Klein, E. A. et al. Androgen deprivation therapy in men with prostate cancer does not affect risk of infection with SARS-CoV-2. J. Urol. 205, 441–443. https://doi.org/10.1097/ju.0000000000001338 (2021).

    Article  PubMed  Google Scholar 

  20. Rastrelli, G. et al. Low testosterone levels predict clinical adverse outcomes in SARS-CoV-2 pneumonia patients. Andrology 9, 88–98. https://doi.org/10.1111/andr.12821 (2021).

    CAS  Article  PubMed  Google Scholar 

  21. Rowland, S. P. & O’Brien Bergin, E. Screening for low testosterone is needed for early identification and treatment of men at high risk of mortality from Covid-19. Crit. Care 24, 367. https://doi.org/10.1186/s13054-020-03086-z (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ding, T. et al. Potential influence of menstrual status and sex hormones on female SARS-CoV-2 infection: A cross-sectional study from multicentre in Wuhan, China. Clin. Infect. Dis. https://doi.org/10.1093/cid/ciaa1022 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  23. Seeland, U. et al. Evidence for treatment with estradiol for women with SARS-CoV-2 infection. BMC Med. 18, 369. https://doi.org/10.1186/s12916-020-01851-z (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  24. Costeira, R. et al. Estrogen and COVID-19 symptoms: Associations in women from the COVID Symptom Study. medRxiv https://doi.org/10.1101/2020.07.30.20164921 (2020).

    Article  Google Scholar 

  25. Lara, O. D. et al. COVID-19 outcomes of patients with gynecologic cancer in New York City. Cancer 126, 4294–4303. https://doi.org/10.1002/cncr.33084 (2020).

    CAS  Article  PubMed  Google Scholar 

  26. Mengying, S. et al. Sex differences in viral entry protein expression, host responses to SARS-CoV-2, and in vitro responses to sex steroid hormone treatment in COVID-19. Res. Square https://doi.org/10.21203/rs.3.rs-100914/v1 (2021).

    Article  Google Scholar 

  27. Montopoli, M. et al. Clinical outcome of SARS-CoV-2 infection in breast and ovarian cancer patients who underwent antiestrogenic therapy. Ann. Oncol. https://doi.org/10.1016/j.annonc.2021.01.069 (2021).

    Article  PubMed  Google Scholar 

  28. Team, R. C. R: A Language and Environment for Statistical Computing. https://www.R-project.org/ (R Foundation for Statistical Computing, 2021).

  29. Qiao, Y. et al. Targeting transcriptional regulation of SARS-CoV-2 entry factors ACE2 and TMPRSS2. Proc. Natl. Acad. Sci. USA https://doi.org/10.1073/pnas.2021450118 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  30. Li, M. Y., Li, L., Zhang, Y. & Wang, X. S. Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues. Infect. Dis. Poverty 9, 45. https://doi.org/10.1186/s40249-020-00662-x (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  31. Song, H., Seddighzadeh, B., Cooperberg, M. R. & Huang, F. W. Expression of ACE2, the SARS-CoV-2 receptor, and TMPRSS2 in prostate epithelial cells. Eur. Urol. 78, 296–298. https://doi.org/10.1016/j.eururo.2020.04.065 (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  32. Baratchian, M. et al. Androgen regulation of pulmonary AR, TMPRSS2 and ACE2 with implications for sex-discordant COVID-19 outcomes. Sci. Rep. 11, 11130. https://doi.org/10.1038/s41598-021-90491-1 (2021).

    ADS  CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. Chen, J. et al. Individual variation of the SARS-CoV-2 receptor ACE2 gene expression and regulation. Aging Cell https://doi.org/10.1111/acel.13168 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  34. Stelzig, K. E. et al. Estrogen regulates the expression of SARS-CoV-2 receptor ACE2 in differentiated airway epithelial cells. Am. J. Physiol. Lung Cell Mol. Physiol. 318, L1280-l1281. https://doi.org/10.1152/ajplung.00153.2020 (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  35. Muus, C. et al. Single-cell meta-analysis of SARS-CoV-2 entry genes across tissues and demographics. Nat. Med. 27, 546–559. https://doi.org/10.1038/s41591-020-01227-z (2021).

    CAS  Article  PubMed  Google Scholar 

  36. Baughn, L. B. et al. Targeting TMPRSS2 in SARS-CoV-2 Infection. Mayo Clin. Proc. 95, 1989–1999. https://doi.org/10.1016/j.mayocp.2020.06.018 (2020).

    CAS  Article  PubMed  Google Scholar 

  37. Chakladar, J. et al. Smoking-mediated upregulation of the androgen pathway leads to increased SARS-CoV-2 susceptibility. Int. J. Mol. Sci. 21, 3627. https://doi.org/10.3390/ijms21103627 (2020).

    CAS  Article  PubMed Central  Google Scholar 

  38. Sarver, D. C. & Wong, G. W. Obesity alters Ace2 and Tmprss2 expression in lung, trachea, and esophagus in a sex-dependent manner: Implications for COVID-19. Biochem. Biophys. Res. Commun. https://doi.org/10.1016/j.bbrc.2020.10.066 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  39. Ghandehari, S. et al. Progesterone in addition to standard of care versus standard of care alone in the treatment of men hospitalized with moderate to severe COVID-19: A randomized, controlled pilot trial. Chest https://doi.org/10.1016/j.chest.2021.02.024 (2021).

    Article  PubMed  Google Scholar 

  40. Jakovac, H. Sex differences in COVID-19 course and outcome: Progesterone should not be neglected. J. Appl. Physiol. 1985(129), 1007–1008. https://doi.org/10.1152/japplphysiol.00740.2020 (2020).

    CAS  Article  Google Scholar 

  41. Linschoten, M. et al. Cardiac complications in patients hospitalised with COVID-19. Eur. Heart J. Acute Cardiovasc. Care 9, 817–823. https://doi.org/10.1177/2048872620974605 (2020).

    Article  PubMed  Google Scholar 

  42. Bristow, M. R. et al. Dynamic regulation of SARS-Cov-2 binding and cell entry mechanisms in remodeled human ventricular myocardium. JACC Basic Transl. Sci. 5, 871–883. https://doi.org/10.1016/j.jacbts.2020.06.007 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Dalpiaz, P. L. et al. Sex hormones promote opposite effects on ACE and ACE2 activity, hypertrophy and cardiac contractility in spontaneously hypertensive rats. PLoS ONE 10, e0127515. https://doi.org/10.1371/journal.pone.0127515 (2015).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  44. Stegbauer, J. et al. Proteomic analysis reveals upregulation of ACE2 (angiotensin-converting enzyme 2), the putative SARS-CoV-2 receptor in pressure-but not volume-overloaded human hearts. Hypertension 76, e41–e43. https://doi.org/10.1161/hypertensionaha.120.16261 (2020).

    CAS  Article  PubMed  Google Scholar 

  45. Gupte, M. et al. Angiotensin converting enzyme 2 contributes to sex differences in the development of obesity hypertension in C57BL/6 mice. Arterioscler. Thromb. Vasc. Biol. 32, 1392–1399. https://doi.org/10.1161/ATVBAHA.112.248559 (2012).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  46. Ji, H. et al. Sex-specific modulation of blood pressure and the renin-angiotensin system by ACE (angiotensin-converting enzyme) 2. Hypertension 76, 478–487. https://doi.org/10.1161/hypertensionaha.120.15276 (2020).

    CAS  Article  PubMed  Google Scholar 

  47. Bénéteau-Burnat, B., Baudin, B., Morgant, G., Baumann, F. C. & Giboudeau, J. Serum angiotensin-converting enzyme in healthy and sarcoidotic children: Comparison with the reference interval for adults. Clin. Chem. 36, 344–346 (1990).

    Article  PubMed  Google Scholar 

  48. Maksimowski, N., Williams, V. R. & Scholey, J. W. Kidney ACE2 expression: Implications for chronic kidney disease. PLoS ONE 15, e0241534. https://doi.org/10.1371/journal.pone.0241534 (2020).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Funding

This study was supported by grants from the Swiss National Science Foundation (SNSF, #31CA30_196140) and the LOOP, Zurich, Switzerland.

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C.G. and S.B. wrote the manuscript with support from V.R.Z., G.M.K., A.M., V.R.Z., and C.E.G. S.B., A.P., and A.H. carried out the animal experiments. M.H., M.G., and A.P. analysed the tissue and blood samples. C.G. and A.M. developed the original idea and supervised the project. A.M. and C.E.G. contributed to the interpretation of the results. A.T., C.G., N.M., and A.R. analysed the data and designed the figures. All authors provided critical feedback and approved the final version of the manuscript.

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Correspondence to Catherine Gebhard.

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Bengs, S., Rossi, A., Haberecker, M. et al. Immunoreactivity of the SARS-CoV-2 entry proteins ACE-2 and TMPRSS-2 in murine models of hormonal manipulation, ageing, and cardiac injury. Sci Rep 11, 23993 (2021). https://doi.org/10.1038/s41598-021-03181-3

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