The COV50 classifier predicts frailty and future death, independent from SARS-CoV-2 infection (preprint)

COV50, a urinary proteomic classifier, predicts disease progression and death from SARS-CoV-2 at early stage, suggesting it might predict pre-established vulnerability. This study investigated the value of COV50 in predicting non-COVID-19 associated death. Urinary proteomic data were extracted from the Human Urinary Proteome Database. In the ICU group (n=1719), an increase in the COV50 score of one unit resulted in a 20% higher relative risk of death (adj. HR 1.2 [95% CI 1.17-1.24]). The same increase in COV50 in non-ICU patients (n=7474) resulted in a higher relative risk of 61% (adj. HR 1.61 [95% CI 1.47-1.76]), in line with adjusted meta-analytic HR estimate of 1.55. A higher COV50 scoring was observed in frail patients (p<0.0001). The COV50 classifier is predictive of death, and is associated with frailty suggesting that it detects pre-existing vulnerability. These data may serve as basis for proteomics guided intervention, reducing the risk of death and frailty.

Predictive performance and clinical application of COV50, a urinary proteomic biomarker in early COVID-19 infection: a cohort study (preprint)

Background The SARS CoV-2 pandemic remains a worldwide challenge. The CRIT Cov U pilot study generated a urinary proteomic biomarker consisting of 50 peptides (COV50), which predicted death and disease progression. Following the interim analysis demanded by the German government, the full dataset was analysed to consolidate findings and propose clinical applications. Methods In eight European countries, 1012 adults with PCR-confirmed COVID-19 were followed up for death and progression along the 8 point WHO scale. Capillary electrophoresis coupled with mass spectrometry was used for urinary proteomic profiling. Statistical methods included logistic regression, receiver operating curve analysis with comparison of the area under curve (AUC) between nested models. Hospitalisation costs were derived from the care facility corresponding with the Markov chain probability of reaching WHO scores ranging from 3 to 8 and flat-rate hospitalistion costs standardised across countries. Findings The entry WHO scores were 1-3, 4-5 and 6 in 445 (44,0%), 529 (52,3%), and 38 (3,8%) patients, of whom 119 died and 271 progressed. The standardised odds ratios associated with COV50 for death were 2,44 (95% CI, 2,05-2,92) unadjusted and 1,67 (1,34-2,07) if adjusted for sex, age, body mass index, comorbidities and baseline WHO score, and 1,79 (1,60-2,01) and 1,63 (1,40-1,90), respectively, for disease progression (p<0,0001 for all). The predictive accuracy of optimised COV50 thresholds were 74,4% (95% CI, 71,6-77,1) for mortality (threshold 0,47) and 67,4% (64,1-70,3) for disease progression (threshold 0,04). On top of covariables and the baseline WHO score, these thresholds improved AUCs from 0,835 to 0,853 (p=0,0331) and from 0,697 to 0,730 (p=0,0008) for death and progression, respectively. Of 196 ambulatory patients, 194 (99,0%) did not reach the 0,04 threshold. Earlier intervention guided by high-risk COV50 levels should reduce hospital days with cost reductions expressed per 1000 patient-days ranging from MEuro 1,208 (95% percentile interval, 1,035-1,406) at low risk (COV50 <0,04) to MEuro 4,503 (4,107-4,864) at high risk (COV50 above 0,04 and age above 65 years). Interpretation The urinary proteomic COV50 marker is accurate in predicting adverse COVID-19 outcomes. Even in mild-to-moderate PCR-confirmed infections (WHO scores 1-5), the 0,04 threshold justifies earlier drug treatment, thereby reducing hospitalisation days and costs.

SGLT2-Inhibition reverts urinary peptide changes associated with severe COVID-19: an in-silico proof-of-principle of proteomics-based drug repurposing (preprint)

Severe COVID-19 is reflected by significant changes in multiple urine peptides. Based on this observation, a clinical test based on urinary peptides predicting COVID-19 severity, CoV50, was developed and registered as IVD in Germany. We have hypothesized that molecular changes displayed by CoV50, to a large degree likely reflective of endothelial damage, can be significantly reversed by specific drugs. To test this hypothesis, we have collected urinary peptide data from patients without COVID-19 prior and after drug treatment. The drugs chosen were selected based on availability of sufficient number of participants in the dataset (n>20) and potential value of drug therapies in the treatment of COVID-19 based on reports in the literature. In these participants without COVID-19, while spironolactone did not demonstrate a significant impact on CoV50 scoring, empagliflozin treatment resulted in a significant change in CoV50 scoring, indicative of a potential therapeutic benefit. The results serve as a proof-of-principle for a drug repurposing approach based on human urinary peptide signatures and support the initiation of a randomised control trial testing a potential positive effect of empagliflozin in the treatment of severe COVID-19, possibly via endothelial protective mechanisms. Significance of the studyCOVID-19 pandemic has imposed a heavy burden on society, health care and economics. Although multiple drugs have been tested in the context of COVID-19, effective treatments for patients experiencing severe disease are still missing, with some drugs demonstrating benefit only at earlier disease stage. Computational drug repurposing emerged as a promising approach to boost drug development, allowing to predict drug efficacy based on the molecular signature of drug impact, mainly using transcriptomics data from cell lines. Recently we demonstrated that urinary proteomics profiles significantly differ between patients with severe COVID-19 course and those with mild/ moderate disease. This resulted in the development of a molecular signature associated with COVID-19 severity (CoV50), allowing to predict COVID-19 course, and enabling guiding intervention. Here we report on the first study demonstrating the application of clinical proteomics data (from clinical trial participants) in a drug repurposing approach. We used the CoV50 signature to examine if the molecular changes associated with COVID-19 severity in patients without COVID-19 might be altered by existing drugs. In a study population without COVID-19, empagliflozin demonstrated a partial, yet significant reversion of the CoV50 signature, indicating a potential benefit in the context of severe COVID-19.

Urinary Peptidomics to Address Age-Related Disabilities (preprint)

Background: The Global Burden Disease 2019 report called for innovation in addressing age-related disabilities. The current study aimed at identifying and validating a urinary peptidomic profile (UPP) differentiating healthy from unhealthy ageing in the general population, to test the UPP predictor in patients, and to search for targetable molecular pathways. Methods: In a Flemish population study (n=778; 50·8% women; age, 16·2-82·1 years), 559 participants were examined twice and made up the derivation and internal validation datasets; 219 were examined once and constituted the independent validation dataset. The UPP was assessed by capillary electrophoresis coupled with mass spectrometry. Statistical methods included linear and proportional hazard regression. Pathway exploration rested on the Reactome and KEGG databases. The multidimensional UPP signature reflecting ageing was further validated in patients with diabetes, COVID-19 or chronic kidney disease. Findings: With correction for multiple testing and multivariable adjustment, chronological age (C‑age) was associated with 210 sequenced peptides mainly showing downregulation of collagen fragments. The trained model relating C‑age to UPP, derived by elastic net regression, included 54 peptides from 17 proteins. In the derivation and the internal and independent validation datasets, the trained model explained 76·3%, 54·4% and 65·3% of C‑age. Compared with the derivation data, the UPP-predicted C‑age was greater (p<0·0001) in age-matched patients with diabetes (n=1575), COVID‑19 infection (n=110) or chronic kidney disease (n=202): 50·3 vs 56·9 vs 58·5 vs 62·3 years. In the population, risk carrying biomarkers were associated (p≤0·037) with UPP‑age, independent of C‑age. Over 12·8‑year (median), the incidence of total and cardiovascular mortality and osteoporosis in the population was associated with UPP‑age, independent of C‑age, with hazard ratios per 10‑year higher UPP‑age of 1·54, 1·72 and 1·40, respectively (p≤0.018). The overrepresented proteins were key nodes in collagen and extracellular-matrix (ECM) turnover. Interpretation: Ageing is associated with a specific UPP signature, reflecting fibrosis and ECM remodelling. UPP‑age was associated with risk factors and adverse health outcomes in the population and with accelerated ageing in patients. Innovation in addressing disability should overcome the ontology of diseases and focus on shared disease mechanisms, in particular the bodywide ageing associated fibrosis and ECM remodelling.Funding: European Research Council, Ministry of the Flemish Community, OMRON Healthcare. Declaration of Interest: HM is the co-founder and co-owner of Mosaiques-Diagnostics GmbH, Hannover, Germany, and AL is an employee of Mosaiques Diagnostics. All other authors declare no conflict of interestEthical Approval: The Flemish Study on Environment, Genes and Health Outcomes (FLEMENGHO) complies with the Helsinki declaration and is registered at the Belgian Data Protection Authority (reference number III 11/1234/13; 22 August 2013). The ethics committee of the University Hospital Leuven, Belgium, approved the secondary use of FLEMENGHO data (national registration number, B32220083510).

Critical COVID-19 represents an endothelial disease with high similarity to kidney disease on the molecular level (preprint)

In patients with critical or mild COVID19 (WHO stages 6-8 [n=53] and stages 1-3 [n=66]), 593 urinary peptides significantly affected by disease severity were identified, reflecting the molecular pathophysiology associated with the course of the infection. The peptide profiles were similar compared with those observed in kidney disease, a prototype of target organ damage with major microvascular involvement, thereby confirming the observation that endothelial damage is a hallmark of COVID19. The clinical corollary is that COVID19 is an indication for anti-oxidative, anti-inflammatory and immunosuppressive treatment modalities protecting the endothelial lining.