NOTCH and tumor necrosis factor-alpha converting enzyme levels could be used in COVID-19 for risk stratification

Dilay Karabulut; Gülçin Şahingöz Erdal; Cennet Yildiz; Gülsüm Oya Hergünsel; Umut Karabulut; Elif Binboğa; Nilgun Isiksacan

doi:10.4103/injms.injms_52_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 13 | Issue : 4 | Page : 221-225

NOTCH and tumor necrosis factor-alpha converting enzyme levels could be used in COVID-19 for risk stratification

Dilay Karabulut¹, Gülçin Şahingöz Erdal², Cennet Yildiz¹, Gülsüm Oya Hergünsel³, Umut Karabulut⁴, Elif Binboğa⁵, Nilgun Isiksacan⁶
¹ Department of Cardiology, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
² Department of Medical Oncology, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
³ Department of Anesthesiology, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
⁴ Department of Cardiology, Acibadem International Hospital, Istanbul, Turkey
⁵ Department of General Surgery, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
⁶ Department of Biochemistry, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey

Date of Submission	29-Apr-2022
Date of Decision	26-Jun-2022
Date of Acceptance	26-Jun-2022
Date of Web Publication	18-Oct-2022

Correspondence Address:
Dr. Cennet Yildiz
Department of Cardiology, Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul
Turkey

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_52_22

Abstract

Background: Novel coronavirus disease-2019 (COVID-19) has become a public emergency that is characterized by a dysregulated immune response and hypercoagulable state. The purpose of the present study was to evaluate NOTCH and tumor necrosis factor-alpha converting enzyme (TACE) levels in COVID-19-infected patients and assess their predictive value on the severity of the disease. Methods: A total of 116 severe-critical COVID-19 patients who were interned intensive care were included in the study. The severity of the disease was evaluated according to the WHO classification system. Patients were divided into two groups according to their cTroponin T (cTnT) levels. Patients who had cTnT levels at least five times the upper limit of normal constituted Group 1 (n = 58); patients who had normal cTnT levels constituted Group 2 (n = 58). Besides, 62 age- and sex-matched healthy controls, who applied to cardiology outward clinic were taken as a control group (Group 3). All patients underwent echocardiographic examination. NOTCH and TACE levels were assessed using enzyme-linked immunosorbent assay. Results: The average age of the patients was 59.96 ± 15.46 years, 92 (51.7%) were female and 86 (48.3%) were male. The mean length of hospital stay was 16.35 ± 10.97 days. NOTCH levels were significantly higher in Group 1 patients compared to Group 2 and control group of patients P = 0.001). NOTCH levels of Group 2 were significantly higher compared to the control group (P = 0.002). Similarly, the TACE levels of Group 1 were significantly higher than that of Group 2 and the control group (P = 0.001). Mortality and length of hospital stay were significantly higher in Group 1 patients compared to Group 2 patients (P = 0.002 and P = 0.004, respectively). TACE levels of deceased patients were significantly higher than that of live patients (P = 0.004). There was a positive relationship between the length of hospital stay and NOTCH levels in Group 1 patients (r = 0.527, P = 0.003). TACE and NOTCH levels were positively correlated with troponin levels (r = 0.627 and r = 0.671, respectively P < 0.001 for both). NOTCH value of 0.34 nmol/L and TACE value of 6.53 μg/mL predicted inhospital mortality with a sensitivity of 90.30% and 63.6% and specificity of 91.5% and 78.6%, respectively. Conclusion: Measurement of NOTCH and TACE levels during severe acute respiratory syndrome coronavirus infection could be helpful for risk stratification.

Keywords: Coronavirus, inflammation, NOTCH, tumor necrosis factor-alpha converting enzyme

How to cite this article:
Karabulut D, Erdal G&, Yildiz C, Hergünsel GO, Karabulut U, Binboğa E, Isiksacan N. NOTCH and tumor necrosis factor-alpha converting enzyme levels could be used in COVID-19 for risk stratification. Indian J Med Spec 2022;13:221-5

How to cite this URL:
Karabulut D, Erdal G&, Yildiz C, Hergünsel GO, Karabulut U, Binboğa E, Isiksacan N. NOTCH and tumor necrosis factor-alpha converting enzyme levels could be used in COVID-19 for risk stratification. Indian J Med Spec [serial online] 2022 [cited 2023 Mar 26];13:221-5. Available from: http://www.ijms.in/text.asp?2022/13/4/221/358776

Introduction

After its first appearance in Wuhan, China, coronavirus disease-2019 (COVID-19) has rapidly spread around the world.^[1] Due to its high contagiosity and a high number of infected patients in a short time, WHO declared it as a global pandemic on March 11, 2020. Clinical presentation of COVID-19 ranges from mild illness to severe forms such as pneumonia, acute respiratory distress syndrome, multiorgan failure, and death.^[2] Studies that have been conducted so far have made clear the pathophysiology of the disease. Augmented immune response with increased production of inflammatory cytokines, which is also known as cytokine storm, can lead to organ failure and death.^[3] Hence, controlling the inflammatory response might be as important as controlling the viral replication cycle.

NOTCH receptor family is a core component of the NOTCH signaling pathway which has an important role in cell specialization, growth, and maturation.^[4] There are four types of NOTCH receptors, activations of which induce the release of NOTCH intracellular domain, downstream target gene expression, and regulation of immune cell function. There is increasing evidence about the role of this pathway in the differentiation and function of T cells, formation of complex structures, the pathogenesis of cancer, endothelial differentiation, and angiogenesis.^{[5],[6],[7],[8]} NOTCH signaling system has been shown to be activated in inflammatory conditions as well as bacterial and viral infections.^{[9],[10],[11]} Levels of NOTCH 1 were found to be increased in biopsies of giant cell arteritis and ulcerative colitis patients.^[12],[13] Available data suggest that the NOTCH pathway plays a critical role in the regulation of innate immunity and inflammation, hence it has become an attractive target for the treatment of various diseases.^[14]

Tumor necrosis factor-alpha (TNF-α) is a potent paracrine and endocrine cytokine that is involved in inflammation, cell proliferation, survival, and apoptosis.^[15] TNF-α levels are increased in chronic inflammatory/infectious diseases, insulin resistance, and acute respiratory distress syndrome.^{[16],[17],[18]} It is generated from its precursor by a membrane-bound metalloproteinase named TNF-α converting enzyme (TACE).^[19] Besides from TNF-α, this enzyme is also responsible for the formation of other membrane-bound proteins including transforming growth factor-α, von Willebrand factor receptor, L-selectin, and vascular cell adhesion protein 1.^[20],[21]

Because both the NOTCH pathway and TACE have important roles in the pathogenesis of inflammatory response, in this study, we aimed to investigate their levels in COVID-19 patients and to evaluate whether they are related to the severity of the disease and inhospital mortality.

Methods

This prospective case–control study enrolled 116 COVID-19 patients who were interned intensive care unit (ICU) in Bakirkoy Dr. Sadi Konuk Education and Research Hospital in Istanbul/Turkey between June and August 2020. Ethical approval was obtained from the local ethical committee (approval number: 2020/194) and the study was directed in conformity with the Declaration of Helsinki. All patients or their legal representatives gave informed consent before study participation. Patients who had negative results for COVID-19 from their nasopharyngeal specimen, under 18-year-old, pregnant women, with congestive heart failure, major valvular abnormalities, and mild and moderate cases were excluded from the study. The severity of the disease was evaluated according to the WHO classification system.^[22] Patients without and with pneumonia were classified as mild and moderate cases, respectively. Patients who had tachypnea (respiratory rate >30/min) and resting oxygen saturation <90% were categorized as “severe” cases. Patients with respiratory failure, acute respiratory distress syndrome, multiorgan failure, and sepsis were categorized as “critical” cases. The extent and localization of lung involvement were assessed by thorax computed tomography images. Patients who had 26%–74% and ≥75% lung involvement were considered to have moderate and severe lung involvement, respectively. All comorbidities of the patients were recorded. NOTCH, TACE, and cTroponin T (cTnT) levels were measured within the first 24 h of ICU admission. If a patient with a normal cTnT level developed an increase in cTnT level during ICU admission then the patient was excluded from the study. Patients were divided into two groups according to their cTnT levels. In our ICU, cTnT levels were routinely measured 3 days a week. Patients who had cTnT levels at least five times the upper limit of normal constituted Group 1 (n = 58); patients who had normal cTnT levels constituted Group 2 (n = 58). Besides, 62 age- and sex-matched healthy controls, who applied to cardiology outward clinic, were taken as a control group (Group 3). All patients underwent echocardiographic examination at least once a week by the same cardiologist experienced in echocardiography.

Blood samples of the patients were drawn by venipuncture in a supine position. All measurements were done within 2 h after sample collection. NOTCH and TACE levels were assessed using enzyme-linked immunosorbent assay.

Statistical analysis

Number Cruncher Statistical System was used for statistical analysis. The normality of the quantitative data was assessed by Shapiro–Wilk test and graphical methods. Comparison of two groups that did not show normal distribution was done using Mann–Whitney U-test. For comparison of more than two groups Kruskal–Wallis test and Dunn–Bonferroni test were used. Correlation between quantitative variables was assessed by Spearman correlation analysis. Receiver operating characteristic curve analysis was done to assess the cut-off values of NOTCH and TACE for the prediction of inhospital mortality. P < 0.05 was considered statistically significant.

Results

The study population was composed of 92 (51.7%) female and 86 (48.3%) male patients. The average age of the patients was 59.96 ± 15.46 (21–92) years. The duration of hospital stay ranged from 4 to 59 days with a mean length of 16.35 ± 10.97 days. All patients were interned in ICU and 22 of them were deceased. Twenty of the deceased patients belonged to Group 1. Forty-eight patients (41.3%) had moderate, and 68 patients (58.7%) had severe pneumonic involvement. We did not find any differences between Group 1 and 2 patients with respect to comorbid diseases. All patients had a normal echocardiographic examination. Clinical characteristics of the study population are given in [Table 1].

Table 1: Clinical characteristics of the study population

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NOTCH levels were found to be significantly different between three groups of patients. NOTCH levels were significantly higher in Group 1 patients compared to Group 2 and control group of patients P = 0.001). NOTCH levels of Group 2 were significantly higher compared to the control group (P = 0.002). Similarly, the TACE levels of Group 1 were significantly higher than that of Group 2 and the control group (P = 0.001). Mortality and length of hospital stay were significantly higher in Group 1 patients compared to Group 2 of patients (P = 0.002 and P = 0.004, respectively) [Table 2]. There were no significant differences in NOTCH and TACE levels between men and women (P = 0.125 and 0.076, respectively). TACE levels of deceased patients were significantly higher than that of live patients (P = 0.004). There was a positive relationship between the length of hospital and NOTCH levels in Group 1 patients (r = 0.527, P = 0.003). TACE and NOTCH levels were positively correlated with troponin levels (r = 0.627 and r = 0.671, respectively P < 0.001 for both). NOTCH value of 0.34 nmol/L and TACE value of 6.53 μg/mL predicted inhospital mortality with a sensitivity of 90.30% and 63.6% and specificity of 91.5% and 78.6%, respectively [Table 3] and [Figure 1].

Figure 1: ROC curve analysis for NOTCH, TACE, and troponin. ROC: Receiver operating characteristic, TACE: Tumor necrosis factor-alpha converting enzyme

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Table 2: Comparison of three groups

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Table 3: Receiver operating characteristics curve analysis for NOTCH, TACE, and hs-Troponin

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Discussion

Our study revealed that NOTCH and TACE levels were increased in severe-critical COVID-19 cases. Moreover, their concentrations began to rise even before cTnT levels became significantly elevated. Patients who had increased values of NOTCH and TACE had a higher length of hospital stay and mortality.

Biomarkers have an important role in clinical decision-making, evaluation of disease severity, and appropriate resource allocation. Various biomarkers such as CRP, interleukin-6, procalcitonin, D-dimer, lactate dehydrogenase, and TNF-α have prognostic value in COVID-19 patients.^{[23],[24],[25]} In the present study, we wanted to evaluate the NOTCH and TACE levels and compare them with cTnT levels. A lot of studies have been conducted to evaluate the value of increased troponins in COVID-19. There is ample evidence suggesting that elevated troponins have prognostic implications in COVID-19.^{[26],[27],[28]} However troponin elevation is not related to the pathologies confined to the cardiovascular system. Other conditions including chronic renal failure, pulmonary embolism, systemic inflammatory response, endothelial cell infection, and endotheliitis also cause troponin rise.^[29],[30] Elevated troponins may reflect more severe disease involvement and predict mortality for both cardiovascular and noncardiovascular causes of COVID-19.^[31] We only included clinically severe and critical patients in our study, and even though cTnT levels were in the normal range, NOTCH and TACE levels were found to be elevated. It must be emphasized that all the patients had normal ejection fractions without major cardiac pathologies and ischemic ECG changes. These two biomarkers could be used in risk stratification for patients who were interned in ICU. Both hospital length of stay and mortality were higher in patients who had a rise in NOTCH and/or TACE levels. NOTCH levels had a positive correlation with the length of hospital stay in Group 1 patients. Both of the variables had a moderate correlation with troponin concentrations. Furthermore, our results showed that NOTCH and TACE levels had predictive value for inhospital mortality with high sensitivity and moderate specificity. Recent studies showed that the NOTCH pathway could enhance severe acute respiratory syndrome coronavirus (SARS-CoV) entry into the cell, augment both inflammation and coagulation cascade and contribute to cardiovascular complications. Endothelial NOTCH receptors may serve as a communication between endothelium and inflammatory cells.^[32] Angiotensin-converting enzyme 2 receptor and SARS-CoV interaction lead to activation of TACE with a resultant increase in interleukin-6 receptor and TNF-α.^{[33],[34],[35]} Because both pathways could be amenable to pharmacological modulation, this might represent a novel therapeutic approach to COVID-19.

Some limitations of the present study were as follows: (1) it was a single-center and observational study, (2) the sample size was relatively small, (3) NOTCH and TACE levels were measured only within the first 24 h of ICU admission and we did not know how the biomarkers varied temporally during admission, and (4) number of deaths in the study population was small and accurate estimation of mortality prediction could not be done.

Conclusion

The results of our study gave additional literature about the activation of inflammatory pathways in COVID-19. It seemed that NOTCH and TACE pathways are activated during SARS-CoV infection. Moreover, their activation had a prognostic value during the disease. Even though the patients had normal cTnT concentrations, their NOTCH and TACE concentrations began to rise. Both of the parameters had predictive value for inhospital mortality. These findings may have important implications regarding prognosis and future treatment options.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

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