SP-D and CC-16 Pneumoproteins' Kinetics and Their Predictive Role During SARS-CoV-2 Infection

Surfactant Protein D and Club Cell Secretory Protein as Biomarkers of Disease Severity and Fostamatinib Efficacy in Severe COVID-19

OBJECTIVES

The objective of the study was to evaluate whether epithelial injury biomarkers-club cell secretory protein (CC16), surfactant protein D (SPD), surfactant protein A (SPA), and receptor for advanced glycation end-products (RAGE)-could prognosticate disease severity and predict treatment responses in hospitalized COVID-19 patients receiving fostamatinib.

DESIGN

Retrospective analysis of samples collected from a randomized, placebo-controlled clinical trial evaluating the safety and efficacy of fostamatinib in hospitalized COVID-19 patients.

SETTING

Hospitalized patients in a multicenter clinical trial.

PATIENTS

Hospitalized COVID-19 patients requiring supplemental oxygen.

INTERVENTIONS

Longitudinal measurement of soluble biomarkers of epithelial injury in patients enrolled in the clinical trial.

MEASUREMENTS AND MAIN RESULTS

Biomarkers of epithelial injury (CC16, SPD, SPA, and RAGE) were measured to assess their prognostic and predictive value. Elevated SPD levels were strongly associated with disease severity and predicted faster clinical improvement with fostamatinib treatment. SPD and CC16 levels remained stable in the fostamatinib group compared with increased levels in the placebo group over 29 days, reflecting alveolar recovery and improved epithelial integrity. SPA and RAGE showed no significant predictive value for clinical outcomes in this setting.

CONCLUSIONS

SPD and CC16 are valuable biomarkers for assessing lung epithelial injury in severe COVID-19. These biomarkers can serve as prognostic indicators of disease severity and predictive markers of response to fostamatinib, guiding therapeutic strategies to improve outcomes in patients with severe respiratory complications.

Clara cell 16 kDa protein: an important marker for COVID-19 severity

The coronavirus disease 19 (COVID-19) is a disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that invades lung epithelial cells and can lead to severe respiratory failure. In this study, we evaluated whether Clara cell 16 kDa protein (CC16), a serum marker of lung alveolar cell damage, is predictive for disease severity. Patients suspected of SARS-CoV-2 infection were included in this study. Serum levels of Clara cell 16 kDa protein (CC16), soluble Fas Ligand, cytochrome C, thymus- and activation regulated chemokine (TARC) and of oxidate stress related proteins were analyzed. Clinical patient data were extracted from the Utrecht Patient Oriented Database. COVID-19 positive patients were divided in two groups according to disease severity. The mean day difference between COVID-19 diagnosis date and sampling date was +11 days. Concentrations of TARC were lower in COVID-19 positive versus COVID-19 negative patients (unpaired t-test, p=0.002). In addition, CC16 serum levels were significantly elevated in sera taken from patients that were admitted at the intensive care unit (ICU) (p=0.0082). In a matched cohort, sera taken prior to ICU admission (-3 days) contained higher CC16 levels (paired t-test, p=0.0072). Multivariable analyses adjusted for known risk factors (age, gender, blood counts, lactate dehydrogenase, c-reactive protein, underlying disease) showed that CC16 levels were independently associated to COVID-19 severity (interquartile-range, odds ratio 1.53, p=0.0102). In conclusion, our findings highlight CC16 as a promising biomarker for early identification of severe COVID19 cases, which could improve patient management and resource allocation.

Detection of serum CC16 by a rapid and ultrasensitive magnetic chemiluminescence immunoassay for lung disease diagnosis

OBJECTIVES

It has been reported that serum Clara cell secreted protein 16 (CC16) is a potential biomarker for lung injury diseases, but currently, there is no other method that is faster, more accurate, or more sensitive being applied in clinical practice apart from ELISA. The current study was designed to established a magnetic nanoparticles chemiluminescence immunoassay (MNPs-CLIA) for highly sensitive automated detection of serum Clara cell secretory protein 16 (CC16), and validated its diagnostic performance for lung disease.

METHODS

The study included the expression of CC16 recombinant protein, the preparation and screening of its monoclonal antibody (MAb), as well as the construction, optimization and analytical evaluation of the MNPs-CLIA method. The clinical application value of this method was investigated by detecting CC16 level in 296 serum samples.

RESULTS

The linear range of the MNPs-CLIA assay system was 0.2-50 ng/mL, and the limit of detection was 0.037 ng/mL. Performance parameters such as specificity, recovery rate, and precision can meet the industry standards of in vitro diagnostic reagents. The established method reveals consistent results with ELISA (R2=0.9962) currently used clinically, and it also exhibits satisfactory diagnostic efficacy of silicosis, chronic obstructive pulmonary disease (COPD), and pulmonary sarcoidosis, with areas under the curve (AUC) of 0.9748, 0.8428 and 0.9128, respectively.

CONCLUSIONS

Our established MNPs-CLIA method has the advantages of automation, high throughput, rapidity, and simplicity, and can be promoted for widely popularized in clinical applications. MNPs-CLIA detection of serum CC16 has efficient diagnostic potentiality for predicting and diagnosing lung diseases.

Nomogram model using serum Club cell secretory protein 16 to predict prognosis and acute exacerbation in patients with idiopathic pulmonary fibrosis

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease with poor prognosis, nomogram model for its prognosis and acute exacerbation was constructed.

METHODS

Two hundred and sixty eight patients with IPF were grouped with different severity according to fibrosis area, serum Club cell secretory protein 16(CC16) was compared between these groups. All patients were randomly divided into training and testing sets. COX regression and LASSO algorithm were used to screen featured characteristics. Then nomogram models were constructed, ROC curve, calibration curve and decision curve analysis(DCA) were conducted to evaluate the performance of model. Expression of CC16 were detected in fibrotic human lung tissues, bronchoalveolar lavage fluid (BALF) and Bleomycin(BLM)-treated mouse lung tissues and serums.

RESULTS

Serum CC16 gradually increased with the severity of fibrosis, and was especially high in AE-IPF group. CC16 and diffusion capacity for carbon monoxide (DLCO) were screened as characteristic variables to construct nomogram model for IPF prognosis. The survival was significantly lower in high-risk group scored by the model. The area under ROC curves(AUCs) for 1-year and 2-year mortality prediction were 0.866 and 0.916, respectively. This model performed better than gender-age-physiology (GAP) index for predicting 2-year and 3-year mortality. Another nomogram model for acute exacerbation of IPF based on CC16, Krebs von den Lungen-6(KL-6) and DLCO was developed, the AUC was 0.815. Expression of CC16 obviously up-regulated in fibrotic lung tissues, BALF and BLM-treated mice lung tissues and serums.

CONCLUSIONS

The nomogram model based on CC16 performed good predictive ability for prognosis and acute exacerbation of IPF.

Update prognostic potency of surfactant protein D (SP-D) in the COVID-19 landscape: an In-depth meta-analytical exploration

INTRODUCTION

Surfactant Protein D (SP-D), a key component of the innate immune system, has attracted significant interest for its potential role in the pathophysiology and prognosis of COVID-19. This systematic review and meta-analysis aim to clarify the prognostic importance of SP-D levels in COVID-19 patients.

METHODS

A comprehensive literature search was conducted using PubMed, Web of Science, Cochrane Library, Scopus, EMBASE, and Google Scholar, covering studies published from January 2000 to January 2024. The inclusion criteria focused on studies measuring SP-D levels in the serum or plasma of COVID-19 patients, comparing severe and non-severe cases. Standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated using a random-effects model to assess overall effect sizes. Meta-regressions and subgroup analyses were performed to identify potential sources of heterogeneity, including patient age, assay techniques, and gender ratio.

RESULTS

The meta-analysis incorporated data from nine studies involving 5,410 COVID-19 patients. Elevated SP-D levels were significantly correlated with increased disease severity, yielding an SMD of 0.642 (95% CI: 0.314 to 0.870; p = 0.012).

CONCLUSION

This meta-analysis confirms the prognostic significance of SP-D in the context of COVID-19. Elevated SP-D levels are associated with severe disease outcomes, highlighting its potential as a prognostic biomarker.

A narrative review on lung injury: mechanisms, biomarkers, and monitoring

Lung injury is closely associated with the heterogeneity, severity, mortality, and prognosis of various respiratory diseases. Effective monitoring of lung injury is crucial for the optimal management and improved outcomes of patients with lung diseases. This review describes acute and chronic respiratory diseases characterized by significant lung injury and current clinical tools for assessing lung health. Furthermore, we summarized the mechanisms of lung cell death observed in these diseases and highlighted recently identified biomarkers in the plasma indicative of injury to specific cell types and scaffold structure in the lung. Last, we propose an artificial intelligence-driven lung injury monitoring model to assess disease severity, and predict mortality and prognosis, aiming to achieve precision and personalized medicine.

Club Cell Secretory Protein-16 (CC16) as a Prognostic Biomarker for COVID-19 and H1N1 Viral Infections

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and H1N1 viruses are inflammatory lung pathogens that can lead to acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). ALI/ARDS are still life-threatening diseases in critically ill patients with 30-40% mortality in the last decade. Currently, there are no laboratory tests for the early diagnosis or prognosis of ALI/ARDS. Club cell secretory protein (CC16) has been investigated as a potential biomarker of lung epithelial damage in various lung diseases. In this study, we evaluated whether plasma CC16 reflects the severity of COVID-19 and H1N1 infections. The plasma CC16 levels showed no significant differences between H1N1 and COVID-19 groups (p = 0.09). Among all subjects, CC16 levels were significantly higher in non-survivors than in survivors (p = 0.001). Upon the area under the receiver operating characteristic (AUROC) analysis, CC16 had an acceptable value to distinguish survivors and non-survivors (p = 0.002). In the COVID-19 group, plasma CC16 levels moderately correlated with the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (r = 0.374, p = 0.003) and Sequential Organ Failure Assessment (SOFA) score (r = 0.474, p < 0.001). In the H1N1 group, a positive correlation was observed between the CC16 levels and hospital length of stay (r = 0.311, p = 0.022). Among all the patients, weak correlations between plasma CC16 levels with the SOFA score (r = 0.328, p < 0.001) and hospital length of stay (r = 0.310, p < 0.001) were observed. Thus, circulating CC16 might reflect the severity of COVID-19 and H1N1 infections.

The multiple facets of the club cell in the pulmonary epithelium

The non-ciliated bronchiolar cell, also referred to as "club cell", serves as a significant multifunctional component of the airway epithelium. While the club cell is a prominent epithelial type found in rodents, it is restricted to the bronchioles in humans. Despite these differences, the club cell's importance remains undisputed in both species due to its multifunctionality as a regulatory cell in lung inflammation and a stem cell in lung epithelial regeneration. The objective of this review is to examine different aspects of club cell morphology and physiology in the lung epithelium, under both normal and pathological conditions, to provide a comprehensive understanding of its importance in the respiratory system.

Cardiopulmonary Complications after Pulmonary Embolism in COVID-19

Although pulmonary embolism (PE) is a frequent complication in COVID-19, its consequences remain unknown. We performed pulmonary function tests, echocardiography and computed tomography pulmonary angiography and identified blood biomarkers in a cohort of consecutive hospitalized COVID-19 patients with pneumonia to describe and compare medium-term outcomes according to the presence of PE, as well as to explore their potential predictors. A total of 141 patients (56 with PE) were followed up during a median of 6 months. Post-COVID-19 radiological lung abnormalities (PCRLA) and impaired diffusing capacity for carbon monoxide (DLCOc) were found in 55.2% and 67.6% cases, respectively. A total of 7.3% had PE, and 6.7% presented an intermediate-high probability of pulmonary hypertension. No significant difference was found between PE and non-PE patients. Univariate analysis showed that age > 65, some clinical severity factors, surfactant protein-D, baseline C-reactive protein, and both peak red cell distribution width and Interleukin (IL)-10 were associated with DLCOc < 80%. A score for PCRLA prediction including age > 65, minimum lymphocyte count, and IL-1β concentration on admission was constructed with excellent overall performance. In conclusion, reduced DLCOc and PCRLA were common in COVID-19 patients after hospital discharge, but PE did not increase the risk. A PCRLA predictive score was developed, which needs further validation.

Could SP-A and SP-D Serum Levels Predict COVID-19 Severity?

Given the various clinical manifestations that characterize Coronavirus Disease 2019 (COVID-19), the scientific community is constantly searching for biomarkers with prognostic value. Surfactant proteins A (SP-A) and D (SP-D) are collectins that play a crucial role in ensuring proper alveolar function and an alteration of their serum levels was reported in several pulmonary diseases characterized by Acute Respiratory Distress Syndrome (ARDS) and pulmonary fibrosis. Considering that such clinical manifestations can also occur during Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, we wondered if these collectins could act as prognostic markers. In this regard, serum levels of SP-A and SP-D were measured by enzyme immunoassay in patients with SARS-CoV-2 infection (n = 51) at admission (T0) and after seven days (T1) and compared with healthy donors (n = 11). SP-D increased in COVID-19 patients compared to healthy controls during the early phases of infection, while a significant reduction was observed at T1. Stratifying SARS-CoV-2 patients according to disease severity, increased serum SP-D levels were observed in severe compared to mild patients. In light of these results, SP-D, but not SP-A, seems to be an eligible marker of COVID-19 pneumonia, and the early detection of SP-D serum levels could be crucial for preventive clinical management.

Effects of lifestyle and associated diseases on serum CC16 suggest complex interactions among metabolism, heart and lungs

INTRODUCTION

Clara cell 16-kDa protein (CC16) is an anti-inflammatory, immunomodulatory secreted pulmonary protein with reduced serum concentrations in obesity according to recent data.

OBJECTIVE

Studies focused solely on bodyweight, which does not properly reflect obesity-associated implications of the metabolic and reno-cardio-vascular system. The purpose of this study was therefore to examine CC16 in a broad physiological context considering cardio-metabolic comorbidities of primary pulmonary diseases.

METHODS

CC16 was quantified in serum samples in a subset of the FoCus (N = 497) and two weight loss intervention cohorts (N = 99) using ELISA. Correlation and general linear regression analyses were applied to assess CC16 effects of lifestyle, gut microbiota, disease occurrence and treatment strategies. Importance and intercorrelation of determinants were validated using random forest algorithms.

RESULTS

CC16 A38G gene mutation, smoking and low microbial diversity significantly decreased CC16. Pre-menopausal female displayed lower CC16 compared to post-menopausal female and male participants. Biological age and uricosuric medications increased CC16 (all p < 0.01). Adjusted linear regression revealed CC16 lowering effects of high waist-to-hip ratio (est. -11.19 [-19.4; -2.97], p = 7.99 × 10-3), severe obesity (est. -2.58 [-4.33; -0.82], p = 4.14 × 10-3) and hypertension (est. -4.31 [-7.5; -1.12], p = 8.48 × 10-3). ACEi/ARB medication (p = 2.5 × 10-2) and chronic heart failure (est. 4.69 [1.37; 8.02], p = 5.91 × 10-3) presented increasing effects on CC16. Mild associations of CC16 were observed with blood pressure, HOMA-IR and NT-proBNP, but not manifest hyperlipidemia, type 2 diabetes, diet quality and dietary weight loss intervention.

CONCLUSION

A role of metabolic and cardiovascular abnormalities in the regulation of CC16 and its modifiability by behavioral and pharmacological interventions is indicated. Alterations by ACEi/ARB and uricosurics could point towards regulatory axes comprising the renin-angiotensin-aldosterone system and purine metabolism. Findings altogether strengthen the importance of interactions among metabolism, heart and lungs.

Advances in Biomarkers for Diagnosis and Treatment of ARDS

Acute respiratory distress syndrome (ARDS) is a common and fatal disease, characterized by lung inflammation, edema, poor oxygenation, and the need for mechanical ventilation, or even extracorporeal membrane oxygenation if the patient is unresponsive to routine treatment. In this review, we aim to explore advances in biomarkers for the diagnosis and treatment of ARDS. In viewing the distinct characteristics of each biomarker, we classified the biomarkers into the following six categories: inflammatory, alveolar epithelial injury, endothelial injury, coagulation/fibrinolysis, extracellular matrix turnover, and oxidative stress biomarkers. In addition, we discussed the potential role of machine learning in identifying and utilizing these biomarkers and reviewed its clinical application. Despite the tremendous progress in biomarker research, there remain nonnegligible gaps between biomarker discovery and clinical utility. The challenges and future directions in ARDS research concern investigators as well as clinicians, underscoring the essentiality of continued investigation to improve diagnosis and treatment.

Molecular Impact of Conventional and Electronic Cigarettes on Pulmonary Surfactant

The alveolar epithelium is covered by a non-cellular layer consisting of an aqueous hypophase topped by pulmonary surfactant, a lipo-protein mixture with surface-active properties. Exposure to cigarette smoke (CS) affects lung physiology and is linked to the development of several diseases. The macroscopic effects of CS are determined by several types of cell and molecular dysfunction, which, among other consequences, lead to surfactant alterations. The purpose of this review is to summarize the published studies aimed at uncovering the effects of CS on both the lipid and protein constituents of surfactant, discussing the molecular mechanisms involved in surfactant homeostasis that are altered by CS. Although surfactant homeostasis has been the topic of several studies and some molecular pathways can be deduced from an analysis of the literature, it remains evident that many aspects of the mechanisms of action of CS on surfactant homeostasis deserve further investigation.

Club Cell Secretory Protein in Lung Disease: Emerging Concepts and Potential Therapeutics

Club cell secretory protein (CCSP), also known as secretoglobin 1A1 (gene name SCGB1A1), is one of the most abundant proteins in the lung, primarily produced by club cells of the distal airway epithelium. At baseline, CCSP is found in large concentrations in lung fluid specimens and can also be detected in the blood and urine. Obstructive lung diseases are generally associated with reduced CCSP levels, thought to be due to decreased CCSP production or club cell depletion. Conversely, several restrictive lung diseases have been found to have increased CCSP levels both in the lung and in the circulation, likely related to club cell dysregulation as well as increasedlung permeability. Recent studies demonstrate multiple mechanisms by which CCSP dampens acute and chronic lung inflammation. Given these anti-inflammatory effects, CCSP represents a novel potential therapeutic modality in lung disease.

Brief Research Report: Serum clara cell 16 kDa protein levels are increased in patients hospitalized for severe SARS-CoV-2 or sepsis infection

Background

Clara cell 16 kDa protein (CC16) is a secretory protein primarily expressed in epithelial cells in the lungs. Previous studies show that CC16 exerts anti-inflammatory and immune-modulatory properties in both acute and chronic pulmonary diseases. However, despite the evidence of CC16’s high biomarker potential, evaluation of its role in infectious diseases is yet very limited.

Methods

Serum CC16 concentrations were measured by ELISA and assessed in two different types of severe infections. Using a case-control study design, patients treated for either severe SARS-CoV-2 or severe non-pulmonary sepsis infection were compared to age- and sex-matched healthy human subjects.

Results

Serum CC16 was significantly increased in both types of infection (SARS-CoV-2: 96.22 ± 129.01 ng/ml vs. healthy controls: 14.05 ± 7.48 ng/ml, p = 0.022; sepsis: 35.37 ± 28.10 ng/ml vs. healthy controls: 15.25 ± 7.51 ng/ml, p = 0.032) but there were no distinct differences between infections with and without pulmonary focus (p = 0.089). Furthermore, CC16 serum levels were positively correlated to disease duration and inversely to the platelet count in severe SARS-CoV-2 infection.

Conclusions

Increased CC16 serum levels in both SARS-CoV-2 and sepsis reinforce the high potential as a biomarker for epithelial cell damage and bronchoalveolar−blood barrier leakage in pulmonary as well as non-pulmonary infectious diseases.

CAN PULMONARY SURFACTANT PROTEINS BE RELIABLE INDICATORS OF COVID-19-ASSOCIATED PULMONARY INJURY?

The COVID-19 pandemic is still raging all over the world. New variants of the coronavirus emerge and infect recovered from previous infections, vaccinated, and unvaccinated subjects. One aspect remains unchanged that is the lungs are the main targets of the pandemic coronavirus. This challenging situation requires the search for reliable predictive markers of severe and complicated course of the disease. Serum surfactant proteins are known to correlate with pulmonary injury severity in numerous diseases. Measurement of such protein levels may help timely predict the risk. Surfactant proteins can also be helpful diagnostic purposes in COVID-19.