Efficacy and safety of metabolic interventions for the treatment of severe COVID-19: in vitro, observational, and non-randomized open label interventional study
- Hebrew University of Jerusalem, Israel
- Barzilai Medical Center, Israel
- Sheba Medical Center, Israel
- Shamir (Assaf Harofeh) Medical Center, Israel
- Broad Institute, United States
- Jerusalem College of Technology, Israel
- Tel Aviv Sourasky Medical Center, Israel
- Policlinico S.Orsola-Malpighi, Italy
- Università degli Studi di Milano, Italy
- Niguarda Hospital, Italy
- University of Pennsylvania, United States
- BioStats Statistical Consulting Ltd, Israel
Abstract
Background: Viral infection is associated with a significant rewire of the host metabolic pathways, presenting attractive metabolic targets for intervention.
Methods: We chart the metabolic response of lung epithelial cells to SARS-CoV-2 infection in primary cultures and COVID-19 patient samples and perform in vitro metabolism-focused drug screen on primary lung epithelial cells infected with different strains of the virus. We perform observational analysis of Israeli patients hospitalized due to COVID-19 and comparative epidemiological analysis from cohorts in Italy and the Veteran's Health Administration in the United States. In addition, we perform a prospective non-randomized interventional open-label study in which 15 patients hospitalized with severe COVID-19 were given 145 mg/day of nanocrystallized fenofibrate added to the standard of care.
Results: SARS-CoV-2 infection produced transcriptional changes associated with increased glycolysis and lipid accumulation. Metabolism-focused drug screen showed that fenofibrate reversed lipid accumulation and blocked SARS-CoV-2 replication through a PPARa-dependent mechanism in both alpha and delta variants. Analysis of 3,233 Israeli patients hospitalized due to COVID-19 supported in vitro findings. Patients taking fibrates showed significantly lower markers of immunoinflammation and faster recovery. Additional corroboration was received by comparative epidemiological analysis from cohorts in Europe and the United States. A subsequent prospective non-randomized interventional open-label study was carried out on 15 patients hospitalized with severe COVID-19. The patients were treated with 145 mg/day of nanocrystallized fenofibrate in addition to standard-of-care. Patients receiving fenofibrate demonstrated a rapid reduction in inflammation and a significantly faster recovery compared to patients admitted during the same period.
Conclusions: Taken together, our data suggest that pharmacological modulation of PPARa should be strongly considered as a potential therapeutic approach for SARS-CoV-2 infection and emphasizes the need to complete the study of fenofibrate in large randomized controlled clinical trials.
Funding: Funding was provided by European Research Council Consolidator Grants OCLD (project no. 681870) and generous gifts from the Nikoh Foundation and the Sam and Rina Frankel Foundation (YN). The interventional study was supported by Abbott (project FENOC0003).
Clinical trial number: NCT04661930.
Data availability
Software resources: Our custom Cell Analysis CellProfiler® Pipeline is available on https://github.com/avnere/Single-Cell-Analysis-CellProfiler-Pipeline.
-
Transcriptional response to SARS-CoV-2 infectionNCBI Gene Expression Omnibus, GSE147507.
-
Single-cell landscape of bronchoalveolar immune cells in COVID-19 patientsNCBI Gene Expression Omnibus, GSE145926.
-
Primary Human Airway Epithelial Cultures infected with SARS-CoV-2NCBI Gene Expression Omnibus, GSE147507.
Article and author information
Author details
Funding
European Research Council (681870)
- Yaakov Nahmias
Nikoh Foundation
- Yaakov Nahmias
Sam and Rina Frankel
- Yaakov Nahmias
Abbott (FENOC0003)
- Yaakov Nahmias
The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.
Ethics
Human subjects: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.In the observational studies - the Israeli study was approved by the local institutional review board of the Hadassah Medical Center (IRB approval number no. HMO 0247-20) and the local institutional review board of the Ichilov Medical Center (IRB approval number no. 0282-20-TLV). The Italian study was reviewed by the local ethical board (AVEC) of the IRCSS S.Orsola-Malpighi University Hospital (approval number no. code LLD-RP2018).The American study was reviewed by the local institutional review board of the Corporal Michael J. Crescenz VA Medical Center (IRB approval number 01654).The interventional study was conducted in accordance with the Good Clinical Practice guidelines of the International Council for Harmonisation E6 and the principles of the Declaration of Helsinki or local regulations, whichever afforded greater patient protection. The study was reviewed and approved by the Barzilai Medical Center Research Ethics Committee (0105-20-BRZ).Statistical analysis of the Israeli studies was done by BioStats Statistical Consulting Ltd. (Maccabim, Israel), funded by the sponsor. Data management is performed in compliance with GCP and 21 CFR part 1. Statistical analyses and reporting are performed in compliance with E6 GCP, E9, and ISO 14155. Independently validated by the author. Statistical analysis of the Italian study was done by Prof. Arrigo Cicero and Dr. Chiara Pavanello. Statistical analysis of the US study was done by Prof. Jordana Cohen.
Reviewing Editor
- Michael Czech, University of Massachusetts Medical School, United States
Version history
- Preprint posted: August 12, 2021 (view preprint)
- Received: May 3, 2022
- Accepted: January 26, 2023
- Accepted Manuscript published: January 27, 2023 (version 1)
- Version of Record published: February 17, 2023 (version 2)
Copyright
© 2023, Ehrlich et al.
This article is distributed under the terms of the Creative Commons Attribution License permitting unrestricted use and redistribution provided that the original author and source are credited.
Metrics
-
- 735
- Page views
-
- 124
- Downloads
-
- 5
- Citations
Article citation count generated by polling the highest count across the following sources: Crossref, PubMed Central, Scopus.
Download links
A two-part list of links to download the article, or parts of the article, in various formats.
Downloads (link to download the article as PDF)
Open citations (links to open the citations from this article in various online reference manager services)
Cite this article (links to download the citations from this article in formats compatible with various reference manager tools)
Efficacy and safety of metabolic interventions for the treatment of severe COVID-19: in vitro, observational, and non-randomized open label interventional study
eLife 12:e79946.
https://doi.org/10.7554/eLife.79946
Further reading
-
- Cell Biology
- Developmental Biology
Cylicins are testis-specific proteins, which are exclusively expressed during spermiogenesis. In mice and humans, two Cylicins, the gonosomal X-linked Cylicin 1 (Cylc1/CYLC1) and the autosomal Cylicin 2 (Cylc2/CYLC2) genes, have been identified. Cylicins are cytoskeletal proteins with an overall positive charge due to lysine-rich repeats. While Cylicins have been localized in the acrosomal region of round spermatids, they resemble a major component of the calyx within the perinuclear theca at the posterior part of mature sperm nuclei. However, the role of Cylicins during spermiogenesis has not yet been investigated. Here, we applied CRISPR/Cas9-mediated gene editing in zygotes to establish Cylc1- and Cylc2-deficient mouse lines as a model to study the function of these proteins. Cylc1 deficiency resulted in male subfertility, whereas Cylc2-/-, Cylc1-/yCylc2+/-, and Cylc1-/yCylc2-/- males were infertile. Phenotypical characterization revealed that loss of Cylicins prevents proper calyx assembly during spermiogenesis. This results in decreased epididymal sperm counts, impaired shedding of excess cytoplasm, and severe structural malformations, ultimately resulting in impaired sperm motility. Furthermore, exome sequencing identified an infertile man with a hemizygous variant in CYLC1 and a heterozygous variant in CYLC2, displaying morphological abnormalities of the sperm including the absence of the acrosome. Thus, our study highlights the relevance and importance of Cylicins for spermiogenic remodeling and male fertility in human and mouse, and provides the basis for further studies on unraveling the complex molecular interactions between perinuclear theca proteins required during spermiogenesis.
-
- Cell Biology
- Structural Biology and Molecular Biophysics
Previously we showed that 2D template matching (2DTM) can be used to localize macromolecular complexes in images recorded by cryogenic electron microscopy (cryo-EM) with high precision, even in the presence of noise and cellular background (Lucas et al., 2021; Lucas et al., 2022). Here, we show that once localized, these particles may be averaged together to generate high-resolution 3D reconstructions. However, regions included in the template may suffer from template bias, leading to inflated resolution estimates and making the interpretation of high-resolution features unreliable. We evaluate conditions that minimize template bias while retaining the benefits of high-precision localization, and we show that molecular features not present in the template can be reconstructed at high resolution from targets found by 2DTM, extending prior work at low-resolution. Moreover, we present a quantitative metric for template bias to aid the interpretation of 3D reconstructions calculated with particles localized using high-resolution templates and fine angular sampling.
