Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) modulators reduce agonist-induced platelet activation and function. CFTR modulators, such as ivacaftor, present a promising therapeutic strategy in thrombocytopathies, including severe COVID-19. https://bit.ly/3HJykdt
To the Editor:
Recent work identified the chloride channel cystic fibrosis transmembrane conductance regulator (CFTR), mutations of which can cause cystic fibrosis (CF), as an important regulator of platelet function, in that its loss or inhibition causes agonist-induced platelet hyperactivation [1]. Hence, activation of CFTR may conversely present a novel strategy to counteract platelet hypercoagulability. Of late, several groups of CFTR modulators have been clinically approved to boost the abundance and/or channel open probability of CFTR at the cell membrane in CF patients. While originally targeted for specific CFTR mutations, emerging evidence suggests that CFTR modulators may also increase channel activity of wild-type CFTR (CFTRwt). Specifically, the CFTR modulator ivacaftor was shown to 1) increase CFTRwt-mediated short circuit current in epithelia [2], 2) increase CFTRwt-mediated transmembrane Cl− flux in endothelial cells [3], and 3) induce dose-dependent pulmonary artery relaxation in wild-type rats [4]. Analogous increases in CFTRwt activity were reported for the CFTR modulators C18 and lumacaftor [5]. We therefore postulated that ivacaftor may exert anticoagulant effects on platelets independent of CFTR mutations, and assessed its effects on activation, adhesion and aggregation of platelets from healthy donors (HDs).
Stimulation with the platelet agonists adenosine diphosphate (ADP) or thrombin receptor-activating protein-6 (TRAP6) enhanced surface expression of the activation markers CD62p and CD63 on HD platelets. This upregulation was attenuated by pre-treatment with ivacaftor (figure 1a). Forskolin, an effective yet clinically not applicable CFTR activator, was used as positive control based on its ability to induce CFTRwt conductance via phosphorylation of its regulatory (R) domain [6]. We next assessed ivacaftor's effect on agonist-induced increases in intracellular Ca2+ concentration ([Ca2+]i) as key “second messenger” of platelet activation. As previously shown, CFTR dysfunction in platelets results in agonist-induced hyperactivation and increased Ca2+ entry [1]. Activation with either ADP or TRAP6 induced a robust [Ca2+]i response, which was attenuated by pre-treatment with ivacaftor, qualitatively replicating the effects of forskolin (figure 1b and c). Analogously, ivacaftor pre-treatment reduced agonist-induced aggregation of HD platelets ex vivo (figure 1d) and diminished platelet adhesion in unstimulated and platelet-agonist stimulated whole blood of HDs in an in vitro model mimicking platelet–extracellular matrix interaction (figure 1e).
Pre-treatment with ivacaftor reduces platelet activation, adhesion and aggregation. Platelets from healthy donors (HDs) were pre-treated with vehicle, 10 µM ivacaftor, or 5 µM forskolin prior to stimulation with 5 µM TRAP6 or 10 µM ADP, or without (w/o) stimulation. a) Surface expression of CD62p and CD63 on CD42b+ platelets. b) Agonist-induced [Ca2+]i transients traced as fluorescence ratio of Ca2+-bound (405 nm) to Ca2+-unbound (530 nm) indo-1 AM in CD42b+ platelets. c) Quantification of [Ca2+]i transients in (b) as area under the curve (AUC). d) Agonist-induced aggregation of platelets assessed by impedance aggregometry (Roche, Germany) in hirudin blood samples. e) For platelet adhesion, citrated HD blood was stained with anti-CD42b antibody, and perfused through collagen-IV-coated microchannel flow chambers (Ibidi, Germany). Total CD42b+ covered area was quantified in five randomly selected regions of interest for each experimental condition (ImageJ, Version 13.0.6). f) Overview of COVID-19 patient and HD cohorts, both without cystic fibrosis (CF), sampled at Charité – Universitätsmedizin Berlin, Germany (Pa-COVID-19 cohort study [15] ethics approvals EA2/066/20 and EA2/075/15), and the Amsterdam University Medical Centers, the Netherlands (ethics approval METc-number 2021.0520) according to the World Health Organization (WHO) clinical progression scale for COVID-19. Patient inclusion required a positive PCR test for SARS-CoV-2 and >18 years of age. Patients treated with anti-platelet drugs were excluded. g) Surface expression of CD62p and CD63 on CD42b+ platelets from COVID-19 patients with moderate or severe disease compared to HDs. h) Representative tracings of agonist-induced [Ca2+]i transients in platelets from patients with severe COVID-19 (without CF). i) Quantification of [Ca2+]i transients measured in (h) as AUC. j) Agonist-induced aggregation of platelets from patients with severe COVID-19 (without CF). k) Representative fluorescence microscopy images of CD42b+ platelets from patients with severe COVID-19 (without CF) adhering on collagen-IV following perfusion with re-calcified whole blood pre-treated with vehicle, ivacaftor or forskolin, and stimulated with vehicle or ADP. Scale bar: 100 μm. l) Quantification of platelet-adhesion assessed in (k) as in (e). Graphical representation: Each circle (a, c, d, e, g, i, j, l) represents platelets from an individual HD/patient; lines represent intra-individual comparisons; bars indicate mean. *: p≤0.05; **: p≤0.005; ***: p≤0.001 by two-way ANOVA with Holm-Šídák's multiple comparisons test (a, c, d, e, g, i, j, l). Data are representative of a) n=12, c) n=8, d) n=7–19, e) n=4–8, g) n=20 (all HDs), n=30 for moderate, and n=22 for severe, i) n=8 each for severe, j) n=6–15 for severe, and l) n=6–12 for severe COVID-19 after ADP- or TRAP6-induced platelet activation following pre-treatment with vehicle, ivacaftor or forskolin. ECMO: extracorporeal membrane oxygenation; NIV: noninvasive ventilation.
To translate the emerging anticoagulant effect of CFTR modulators to the clinic, we probed for the association of CFTR modulator therapy with thromboembolic events in CF patients, the only patient group for which CFTR modulators are approved. We retrospectively analysed clinical data of 4012 CF patients receiving single- or combination therapy with ivacaftor, lumacaftor, tezacaftor or elexacaftor, and compared them to 4012 age-, sex-, and medication-matched untreated CF patients from the TriNetX, LLC Real World Database [7]. Propensity score matching was performed for the use of non-steroidal anti-inflammatory drugs, anticoagulants, platelet activation and aggregation inhibitors, catecholamines and other vasopressors, and corticosteroids prior to outcome analysis. CFTR modulator therapy reduced the risk for death and mechanical ventilation by 34.1% (OR 0.483, 95% CI 0.385–0.606) and 40.1% (OR 0.266, 95% CI 0.137–0.519), respectively. This therapeutic effect was closely associated with fewer thromboembolic manifestations, as indicated by a substantial risk reduction for myocardial infarction (MI) (−60.0%; OR 0.371, 95% CI 0.230–0.597), stroke (−55.8%; OR 0.428, 95% CI 0.326–0.563), arterial thrombosis (−54.6%; OR 0.454, 95% CI 0.270–0.762), and pulmonary embolism (−38.1%; OR 0.609, 95% CI 0.429–0.866), while risk reduction for deep vein thrombosis (OR 0.784, 95% CI 0.607–1.012) did not reach significance. To assess whether this preventive effect of CFTR modulators persists in a scenario that predisposes for thromboembolic complications, we next retrospectively analysed a total of 4050 CF patients with acute COVID-19, half of which received CFTR modulators, for the same outcomes. Analogous to results in non-COVID-19 patients, no significant difference was evident in platelet counts (2.7±1.0×105 cells·µL−1 (untreated), 2.8±1.0×105 cells·µL−1 (CFTR modulator)) or in blood clotting ability (prothrombin time: 13.5±10.5 (untreated), 13.4±9.8 s (CFTR-modulator); international normalised ratio: 1.5±4.2 (untreated), 1.3±2.0 (CFTR-modulator)) as a function of CFTR modulator therapy. Yet, risks of fatality (−45.5%; OR 0.529, 95% CI 0.351–0.797) or mechanical ventilation (−53.9%; OR 0.474, 95% CI 0.293–0.767) were again significantly reduced by CFTR modulators, as were risks for MI (−50.0%; OR 0.520, 95% CI 0.306–0.885), stroke (−76.7%; OR 0.222, 95% CI 0.136–0.363), arterial thrombosis (−54.6%; OR 0.432, 95% CI 0.205–0.910), and characteristic COVID-19 associated coagulopathies, namely deep vein thrombosis (−61.1%; OR 0.394, 95% CI 0.255–0.609) and pulmonary embolism (−60.1%; OR 0.386, 95% CI 0.252–0.591).
Based on these epidemiological data indicating a therapeutic effect of CFTR-modulators on hypercoagulopathic and thromboembolic complications in COVID-19, we replicated our analyses of ivacaftor's effects on platelet hyperactivation, adhesion and coagulation in blood of acute COVID-19 patients (figure 1f). Similar to the results shown in figure 1a–e, none of these patients had CF. Relative to HDs, platelets from acute COVID-19 patients showed enhanced surface expression of CD62p and CD63 as a function of disease severity (figure 1g), highlighting the hypercoagulable state in COVID-19. Similar to our findings in HDs, ivacaftor attenuated agonist-induced [Ca2+]i responses in platelets of severe COVID-19 patients (figure 1h and i). While ivacaftor pre-treatment was only moderately effective in reducing TRAP6-induced platelet aggregation in HDs (−12.2%), effectiveness was high in severe COVID-19 patients (−49.2%), qualitatively phenocopying the effect of forskolin (figure 1j). In line with this anticoagulant effect, adhesion of both unstimulated and stimulated platelets in whole blood of severe COVID-19 patients was reduced by ivacaftor (figure 1k and l).
CFTR modulation attenuates platelet activation, adhesion, and aggregation in blood of both HDs and acute COVID-19 patients, and shows promise to reduce thromboembolic complications in the clinic. The extent to which this CFTR-dependent attenuation is mediated by its classic function as chloride channel or by its proposed role in the formation and composition of lipid rafts as signalling hubs remains to be elucidated [8]. As CFTR is also expressed in endothelial cells [9], neutrophils and monocytes, the anticoagulant benefits of CFTR modulator therapy in vivo may in part be attributable to effects on non-platelet cells. As circulating platelet–leukocyte aggregates correlate with COVID-19 severity [10], it remains to be seen whether CFTR-modulators also target, for example, neutrophil activation and aggregate-associated formation of neutrophil extracellular traps in COVID-19 patients [11]. Treatment of COVID-19 patients with aspirin, apixaban or P2Y12 inhibitors failed to yield a significant reduction in thromboembolic events in the multicentre RECOVERY trial [12] or the ACTIV4a trial [13]. Moreover, treatment of platelets of severe COVID-19 patients with aspirin failed to reduce platelet aggregation ex vivo [14]. In contrast, our results demonstrate an anticoagulant effect of ivacaftor ex vivo, especially in platelets from patients with severe COVID-19, suggesting a greater promise of this strategy to reduce the risk for thrombotic events in the clinical management of COVID-19 patients.
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Acknowledgements
We would like to thank all medical, paramedical, laboratory and nursing staff involved in the care of the COVD-19 patients and for realising the patient recruitment at Charité – Universitätmedizin Berlin, Germany, and Amsterdam UMC, The Netherlands.
Furthermore, the authors would like to thank all investigators of the Berlin prospective Pa-COVID-19 cohort: Florian Kurth (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany; Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany), Maria Roennefarth (Clinical Study Center (CSC), Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, Berlin, Germany), Charlotte Thibeault (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Victor M. Corman (Institute of Virology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Holger Müller-Redetzky (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Mirja Mittermaier (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Christoph Ruwwe-Glösenkamp (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Katrin M. Heim (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Alexander Krannich (Clinical Study Center (CSC), Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, Berlin, Germany), Saskia Zvorc (Clinical Study Center (CSC), Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, Berlin, Germany), Sein Schmidt (Clinical Study Center (CSC), Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, Berlin, Germany), Lucie Kretzler (Clinical Study Center (CSC), Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, Berlin, Germany), Chantip Dang-Heine (Clinical Study Center (CSC), Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, Berlin, Germany), Matthias Rose (Department of Psychosomatic Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Michael Hummel (Central Biobank Charité (ZeBanC), Institute of Pathology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Andreas Hocke (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Ralf H. Hübner (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Bastian Opitz (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Marcus A. Mall (Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Jobst Röhmel (Department of Pediatric Pulmonology, Immunology and Critical Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Ulf Landmesser (Department of Cardiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Burkert Pieske (Medical Department, Division of Cardiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Samuel Knauss (Department of Neurology with Experimental Neurology and Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Matthias Endres (Department of Neurology with Experimental Neurology and Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Joachim Spranger (Department of Endocrinology and Metabolism, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Frank P. Mockenhaupt (Institute of Tropical Medicine and International Health Berlin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Frank Tacke (Department of Hepatology and Gastroenterology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Sascha Treskatsch (Department of Anaesthesiology and Intensive Care Medicine, Charite Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Stefan Angermair (Division of Gastroenterology, Infectious Diseases, Rheumatology, Medical Department, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Britta Siegmund (Division of Gastroenterology, Infectious Diseases, Rheumatology, Medical Department, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Claudia Spies (Department of Anesthesiology and Operative Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Steffen Weber-Carstens (Department of Anesthesiology and Operative Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Kai-Uwe Eckardt (Department of Nephrology and Internal Intensive Care Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Dirk Schürmann (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Alexander Uhrig (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Miriam S. Stegemann (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Thomas Zoller (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Christian Drosten (Institute of Virology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Norbert Suttorp (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Martin Witzenrath (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Stefan Hippenstiel (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany), Christof von Kalle (Clinical Study Center (CSC), Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, Berlin, Germany) and Leif Erik Sander (Department of Infectious Diseases and Respiratory Medicine, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany).
Finally, the authors also thank the Amsterdam UMC COVID-19 Biobank investigators: Michiel van Agtmael (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Anne Geke Algera (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Brent Appelman (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Frank van Baarle (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Diane Bax (Experimental Immunology, Amsterdam UMC, Amsterdam, The Netherlands), Martijn Beudel (Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands), Harm Jan Bogaard (Department of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands), Marije Bomers (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands) Peter Bonta (Department of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands), Lieuwe Bos (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Michela Botta (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Justin de Brabander (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Godelieve de Bree (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Sanne de Bruin (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), David T.P. Buis (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Marianna Bugiani (Department of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands), Esther Bulle (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Nora Chekrouni (Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands), Osoul Chouchane (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Alex Cloherty (Experimental Immunology, Amsterdam UMC, Amsterdam, The Netherlands), Mirjam Dijkstra (Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands), Dave A. Dongelmans (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Erik Duijvelaar (Department of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands), Romein W.G. Dujardin (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Paul Elbers (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Lucas Fleuren (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Suzanne Geerlings (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Theo Geijtenbeek (Experimental Immunology, Amsterdam UMC, Amsterdam, The Netherlands), Armand Girbes (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Bram Goorhuis (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Martin P. Grobusch (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Florianne Hafkamp (Experimental Immunology, Amsterdam UMC, Amsterdam, The Netherlands), Laura Hagens (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Jorg Hamann (Amsterdam UMC Biobank Core Facility, Amsterdam UMC, Amsterdam, The Netherlands), Vanessa Harris (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Robert Hemke (Department of Radiology, Amsterdam UMC, Amsterdam, The Netherlands), Sabine M. Hermans (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Leo Heunks (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Markus Hollmann (Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands), Janneke Horn (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Joppe W. Hovius (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Menno D. de Jong (Department of Medical Microbiology, Amsterdam UMC, Amsterdam, The Netherlands), Rutger Koning (Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands), Endry H.T. Lim (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Niels van Mourik (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Jeaninne Nellen (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Esther J. Nossent (Department of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands), Sabine Olie (Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands), Frederique Paulus (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Edgar Peters (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Dan A.I. Pina-Fuentes (Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands), Tom van der Poll (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Bennedikt Preckel (Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands), Jorinde Raasveld (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Tom Reijnders (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Maurits C.F.J. de Rotte (Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands), Job R. Schippers (Department of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands), Michiel Schinkel (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Marcus J. Schultz (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Femke A.P. Schrauwen (Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands), Alex Schuurman (Department of Internal Medicine, Amsterdam UMC, Amsterdam, The Netherlands), Jaap Schuurmans (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Kim Sigaloff (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Marleen A. Slim (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands; and Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Patrick Smeele (Department of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands), Marry Smit (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Cornelis S. Stijnis (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Willemke Stilma (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Charlotte Teunissen (Neurochemical Laboratory, Amsterdam UMC, Amsterdam, The Netherlands), Patrick Thoral (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Anissa M. Tsonas (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Pieter R. Tuinman (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Marc van der Valk (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Denise Veelo (Department of Anesthesiology, Amsterdam UMC, Amsterdam, The Netherlands), Carolien Volleman (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Heder de Vries (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands), Lonneke A. Vught (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands; and Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Michéle van Vugt (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Dorien Wouters (Department of Clinical Chemistry, Amsterdam UMC, Amsterdam, The Netherlands), A.H. (Koos) Zwinderman (Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Amsterdam, The Netherlands), Matthijs C. Brouwer (Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands), W. Joost Wiersinga (Department of Infectious Diseases, Amsterdam UMC, Amsterdam, The Netherlands), Alexander P.J. Vlaar (Department of Intensive Care, Amsterdam UMC, Amsterdam, The Netherlands) and Diederik van de Beek (Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, Amsterdam, The Netherlands).
Footnotes
The data for the retrospective patient data analyses used in this study was collected on 9 August 2022 from the TriNetX COVID-19 Research Network, which provided access to electronic medical records (diagnoses, procedures, medications, laboratory values, genomic information) from approximately 112 million patients from 68 healthcare organisations. TriNetX, LLC is compliant with the Health Insurance Portability and Accountability Act (HIPAA), the US federal law which protects the privacy and security of healthcare data, and any additional data privacy regulations applicable to the contributing HCO. TriNetX is certified to the ISO 27001:2013 standard and maintains an Information Security Management System to ensure the protection of the healthcare data it has access to and to meet the requirements of the HIPAA Security Rule. Any data displayed on the TriNetX Platform in aggregate form, or any patient level data provided in a dataset generated by the TriNetX Platform, only contains de-identified data as per the de-identification standard defined in section §164.514(a) of the HIPAA privacy rule. The process by which the data is de-identified is attested to through a formal determination by a qualified expert as defined in section §164.514(b) (1) of the HIPAA privacy rule. Because this study used only de-identified patient records and did not involve the collection, use or transmittal of individually identifiable data, this study was exempted from institutional review board approval.
Author contributions: E. Asmus, W.M. Kuebler, R. Szulcek and S. Simmons conceived the study. E. Asmus, W. Karle, M.C. Brack, C. Wittig, F. Behrens, L. Reinshagen, S. Schulz, B. Mandzimba-Maloko, L. Erfinanda, P.L. Perret, L. Michalick, P.J. Smeele, C.E. van den Brom, A.B.A. Vonk, T. Kaiser, A. Haghikia, U. Landmesser, N. Suttorp, R. Szulcek and S. Simmons performed experiments, analysed the data and/or provided and collected samples. M. Witzenrath, L.E. Sander, F. Kurth and H.J. Bogaard led the clinical studies. E. Asmus, W.M. Kuebler, R. Szulcek and S. Simmons wrote the manuscript. All authors revised and approved the manuscript.
Conflict of interest: E. Asmus reports European patent application number EP22162072.7 (15 March 2022): CFTR Modulators for the treatment of vascular disease. F. Behrens reports a BIH-MD-TRENAL medical research student stipend and a visiting scientist grant from the German Centre for Cardiovascular Research (DZHK), as well as travel support from Berlin Institute of Health (BIH Biomedical Innovation Academy Mobility and Innovation Grant) and German Centre for Cardiovascular Research (DZHK Travel Grant). L. Erfinanda reports European patent application number 20196830.2 - 1112 (18 September 2020): New medical use of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. P.L. Perret reports a travel grant from the German Centre for Cardiovascular Research (DZHK). L.E. Sander reports grants from the Federal Institute for Drugs and Medical Devices of Germany, the Federal Ministry of Research and Education (Germany), the Germany Research Foundation (DFG) and Miltenyi Biotech, and reports personal fees from GlaxoSmithKline, Novartis, Sanofi, Chiesi, Boehringer and Berlin Chemie. U. Rauch reports personal fees from Bayer Vital GmbH, Sanofi Aventis and Boehringer Ingelheim, and is an advisory board member of Bayer Vital GmbH, Sanofi Aventis and Boehringer Ingelheim; U. Rauch also has a leadership role at ESC. U. Landmesser reports personal fees from Abbott, Amgen Bayer, Cardiac Dimensions, Novartis, Pfizer, Novo Nordisk, Daiichi Sankyo, Sanofi, Boston Scientific, AstraZeneca and Boehringer Ingelheim. R. Preissner reports grants from the German Research Foundation (DFG) and European Patent application number EP22162072.7 (15 March 2022): CFTR modulators for the treatment of vascular disease. M. Witzenrath reports grants from the German Research Foundation (DFG), the Federal Ministry of Education and Research (Germany), the German Respiratory Society, the European Respiratory Society, the Marie Curie Foundation, the Else Kröner Fresenius Foundation, the Capnetz Foundation, the International Max Planck Research School, Actelion, Bayer Health Care, Biotest and Boehringer Ingelheim, reports personal fees from Noxxon, Pantherna, Vaxxilon, Aptarion, GlaxoSmithKline, Sinoxa, Biotest, AstraZeneca, Berlin Chemie, Chiesi, Novartis, Teva, Actelion, Boehringer Ingelheim and Bayer Health Care, and reports patents EPO 12181535.1: IL-27 for modulation of immune response in acute lung injury; WO/2010/094491: Means for inhibiting the expression of Ang-2; DE 102020116249.9: Camostat/Niclosamide cotreatment in SARS-CoV-2 infected human lung cells; and PCT/EP2021/075627: New medical use of cystic fibrosis transmembrane conductance regulator (CFTR) modulators. W.M. Kuebler reports grants from the German Research Foundation (DFG), the German Ministry for Research and Education (BMBF), and the German Centre for Cardiovascular Research (DZHK), and reports personal fees from Bayer AG, Germany, and reports European patent application number 20196830.2 - 1112 (18 September 2020): New medical use of cystic fibrosis transmembrane conductance regulator (CFTR) modulators; and European patent application number EP22162072.7 (15 March 2022): CFTR Modulators for the treatment of vascular disease; W.M. Kuebler is Chair-Elect, Publications Committee, American Physiological Society and President, German Society for Microcirculation and Vascular Biology. R. Szulcek reports European patent application number EP22162072.7 (15 March 2022): CFTR Modulators for the treatment of vascular disease. S. Simmons reports grants from the German Centre for Cardiovascular Research (DZHK) and the German Society for Heart Research, and reports European patent application number EP22162072.7 (15 March 2022): CFTR Modulators for the treatment of vascular disease. The remaining authors report no potential conflicts of interest.
Support statement: F. Behrens received funding from the Berlin Institute of Health (BIH). L. Michalick reports grants from the BIH and the German Centre for Cardiovascular Research (DZHK). A. Haghikia is participant in the BIH-Charité Advanced Clinician Scientist Pilotprogram funded by the Charité – Universitätsmedizin Berlin and the BIH and reports a research grant within the BIH and MDC Focus Area Translational Vascular Biomedicine. R. Preissner reports partial funding of this work by the German Research Foundation (KFO339, TRR295). M. Witzenrath reports grants from the German Research Foundation (SFB-TR84 C06 and C09, SFB 1449 B02), and from the German Ministry of Education and Research (BMBF) in the framework of CAPSyS (01ZX1604B, 01ZX1304B), SYMPATH (01ZX1906A), PROVID (01KI20160A), Phage4Cure (16GW0141), MAPVAP (16GW0247) and NUM-NAPKON. W.M. Kuebler reports grants from the German Research Foundation (SFB-TR84 A2 and C9, SFB 1449 B1, SFB 1470 A4, KU1218/9-1, KU1218/11-1, and KU1218/12-1), the BMBF in the framework of SYMPATH (01ZX1906A) and PROVID (01KI20160A), and the DZHK. S. Simmons reports grants from the DZHK and the German Foundation for Heart Research (F-09-19). Funding information for this article has been deposited with the Crossref Funder Registry.
- Received May 6, 2023.
- Accepted January 31, 2023.
- Copyright ©The authors 2023.
This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0. For commercial reproduction rights and permissions contact permissions{at}ersnet.org
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