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Tug E, Fidan I, Bozdayi G, Yildirim F, Tunccan OG, Lale Z, Akdogan D. The relationship between the clinical course of SARS-CoV-2 infections and ACE2 and TMPRSS2 expression and polymorphisms. ADV CLIN EXP MED 2024; 33:39-51. [PMID: 37326579 DOI: 10.17219/acem/163409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/01/2023] [Accepted: 04/18/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The viral spike (S) protein and host ACE2 and TMPRSS2 genetic variations may act as a barrier to viral infections or determine susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. OBJECTIVES We investigated the relationship between the expression patterns and polymorphisms of the ACE2 and TMPRSS2 receptor genes associated with coronavirus disease 2019 (COVID-19) and the clinical course of SARS-CoV-2 infections. MATERIAL AND METHODS We examined 147 COVID-19 patients (41 asymptomatic, 53 symptomatic and 53 cases treated in the intensive care unit (ICU)) and 33 healthy controls. The ACE2 and TMPRSS2 expression was determined using the One-Run RT-qPCR kit. Genotypic distributions of single nucleotide polymorphisms (SNPs) of ACE2 and TMPRSS2 were obtained using reverse transcription quantitative polymerase chain reaction (RT-qPCR). RESULTS The expressions of ACE2 and TMPRSS2 were different between SARS-CoV-2-positive and -negative groups. The ACE2 rs714205GG genotype and G-allele showed significant differences in the asymptomatic SARS-CoV-2-positive group. A significant correlation was found between the expression of TMPRSS2 rs8134378GA, rs2070788GA, rs7364083GA, and rs9974589AC genotypes and SARS-CoV-2 positivity. The rs1978124 C-allele and rs8134378 A-allele expressions were significant in the symptomatic SARS-CoV-2-positive group. The TMPRSS2 rs2070788GA expression was different in all patient groups compared to the control group. There was a difference between SARS-CoV-2-positive and -negative groups regarding the CTTA haplotype formed by ACE2 variants. The AGCAG and AGAAG haplotypes formed by the TMPRSS2 variants were more common in the asymptomatic patient group than in other patient groups. CONCLUSIONS Identifying the relationship between host genetic variants and COVID-19 susceptibility will contribute to further studies, enabling new vaccines and potential therapeutic approaches to be discovered.
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Affiliation(s)
- Esra Tug
- Department of Medical Genetics, Medical University of Gazi, Turkey
| | - Isil Fidan
- Department of Medical Microbiology, Medical University of Gazi, Turkey
| | - Gulendam Bozdayi
- Department of Medical Microbiology, Medical University of Gazi, Turkey
| | - Fatma Yildirim
- Department of Chest Diseases, Pulmonary Intensive Care Unit, University of Health Sciences, Diskapi Yildirim Beyazit Research and Education Hospital, Turkey
| | | | - Zubeyde Lale
- Department of Medical Microbiology, Dışkapı Yıldırım Beyazit Research and Education Hospital, Turkey
| | - Dogan Akdogan
- Department of Medical Microbiology, Pursaklar State Hospital, Turkey
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Faustine I, Marteka D, Malik A, Supriyanto E, Syafhan NF. Genotype variation of ACE and ACE2 genes affects the severity of COVID-19 patients. BMC Res Notes 2023; 16:194. [PMID: 37667339 PMCID: PMC10478384 DOI: 10.1186/s13104-023-06483-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVE Genetic polymorphisms in ACE and ACE2 genes are involved in the RAS regulation of blood pressure and their activity may confer susceptibility to hypertension. In addition, they may play a role in SARS-CoV-2 pathogenesis and the severity of COVID-19. This study aims to determine the effect of genetic variations in the ACE (rs4331) and ACE2 (rs2074192) genes with hypertension comorbidity on the severity of COVID-19 in the Indonesian population. RESULT 186 patients were enrolled and assigned into the COVID-19 group (n = 95) and non-COVID-19 group (n = 91) in this cross-sectional study. GG genotype frequency was dominant in ACE gene, but there were no significant differences between the groups (p = 0.163). The two groups had a significant difference (p = 0.000) for the CC genotype frequency (0,37 vs. 0.01) in the ACE2 gene. The proportion of women with COVID-19 is higher (51%), but men with hypertension had more severe symptoms (44%). Men with hypertension comorbidity, GG (ACE), and TT (ACE2) genotypes tended to have moderate-to-severe symptoms (25%). Similarly, women with hypertension as well as GG and CT genotypes tended to have moderate-to-severe symptoms (21%). We conclude that hypertension and mutations in the ACE (rs4331) and ACE2 (rs2074192) genes affect the severity of COVID-19.
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Affiliation(s)
- Ingrid Faustine
- Faculty of Pharmacy, Universitas Indonesia, Depok, 16424, West Java, Indonesia
- Department of Pharmacy, Faculty of Mathematics and Natural Sciences, Tadulako University, Palu, 94148, Central Sulawesi, Indonesia
| | - Deli Marteka
- Faculty of Pharmacy, Universitas Indonesia, Depok, 16424, West Java, Indonesia
| | - Amarila Malik
- Division of Pharmaceutical Microbiology and Biotechnology, Faculty of Pharmacy, Universitas Indonesia, Depok, 16424, West Java, Indonesia.
| | - Eko Supriyanto
- Department of Biomedical Engineering & Health Science, Universiti Teknologi Malaysia, Johor Bahru, Johor, 81310, Malaysia
| | - Nadia F Syafhan
- Division of Clinical Pharmacy, Faculty of Pharmacy, Universitas Indonesia, Depok, 16424, West Java, Indonesia
- Universitas Indonesia Hospital, Jl. Prof. Dr. Bahder Djohan, Pondok Cina, Depok, 16424, West Java, Indonesia
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Rifaat Muhammad H, Obaid Othman G. Molecular Study of ACE2 Gene Polymorphism of COVID-19 Infection among the Kurdish Population in Kurdistan Region- Iraq. Arch Razi Inst 2023; 78:161-166. [PMID: 37312735 PMCID: PMC10258245 DOI: 10.22092/ari.2022.358492.2232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
Coronavirus Disease 2019 (COVID-19) is a current pandemic infection of the human respiratory system, which is caused by which caused by Sever Acute respiratory syndrome virus 2 (SARS-CoV-2). The infection was classified by World Health Organization (WHO) as a universal pandemic in February 2020; there have been 494.587.638 confirmed cases and 6.170.283 deaths. The present study investigated the molecular genetics of the Angiotensin Converting Enzyme 2 (ACE2) gene in correlation to COVID-19 patients in the Kurdish population. Eighty-six individuals were clinically diagnosed with COVID-19 and control groups. After the genomic DNA extraction these participants the target 1, 2 and 8 exons of the ACE2 gene were amplified using the PCR technique, and then the Sanger sequencing technique was performed to analyze genetic variants of the ACE2 gene in 70 DNA samples of COVID-19 hospital patients at Emergency Hospital in Erbil city, Sarchnar Hospital in Sulaymaniyah city, Lalav Hospital in Duhok city and Wafa Hospital in Halabja city from Kurdistan Region of Iraq. The current study was designed into two groups control group and a patient group. The patient group was divided into two subgroups, severe and mild patients of different ages and genders. As a result, there were no mutations at the positions 1, 2 and 8 exons sequences, while single nucleotide polymorphisms (SNPs) were detected and identified three different types of mutation at intron position: twenty-six of c.12405 del T, two of c.12407 T>G, and two of c.12406 G>A in a total 86 participants. This result shows that genetic difference does not impact the COVID-19 infection severity among the Kurdish population regarding ACE2 gene polymorphism.
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Affiliation(s)
- H Rifaat Muhammad
- Biology Department, College of Education, Salahaddin University, Erbil, Iraq
| | - G Obaid Othman
- Biology Department, College of Education, Salahaddin University, Erbil, Iraq
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Pouladi N, Abdolahi S. Investigating the ACE2 polymorphisms in COVID-19 susceptibility: An in silico analysis. Mol Genet Genomic Med 2021; 9:e1672. [PMID: 33818000 PMCID: PMC8222831 DOI: 10.1002/mgg3.1672] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/14/2021] [Accepted: 03/22/2021] [Indexed: 01/19/2023] Open
Abstract
Background Novel coronavirus (SARS‐CoV‐2) became an epidemic disease and lead to a pneumonia outbreak first in December 2019 in Wuhan, China. The symptoms related to coronavirus disease‐19 (COVID‐19) were different ranging from mild to severe lung injury and multi‐organ failure symptoms, eventually leading to death, especially in older patients with other co‐morbidities. The receptor of this virus in the human cell is angiotensin‐converting enzyme 2 (ACE2). Methods In this paper, we aimed to perform an in silico analysis of the frequently studied variants of the ACE2 gene and determine the effects of the variants in mRNA secondary structure and binding affinity of cellular factors. Fourteen single‐nucleotide polymorphisms were selected based on previous studies and investigated. Results All of the variants were analyzed in the RNAsnp database and three revealed a significant p‐value. The spliceAid2 database prediction showed that 7 out of 14 SNPs caused an alteration in a way that only the wild or mutated form was able to bind to proteins. The latter database also reported that three SNPs produces a dual form in which different specific proteins can bind to the sequence in a specific form (either wild or mutated form). Conclusion Altogether, these estimations revealed the potential of variants in manipulation of the final stable form of ACE2 that can lead to different COVID‐19 susceptibility.
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Affiliation(s)
- Nasser Pouladi
- Department of Biology, Faculty of Basic Science, Azarbaijan Shahid Madani University, Tabriz, Iran.,Department of Molecular Biology and Cancer Research, Azarbaijan Shahid Madani University, Tabriz, Iran
| | - Sepehr Abdolahi
- Department of Molecular Biology and Cancer Research, Azarbaijan Shahid Madani University, Tabriz, Iran.,Department of Biology, Faculty of Basic Science, Azarbaijan Shahid Madani University, Tabriz, Iran
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Cao Y, Sun Y, Tian X, Bai Z, Gong Y, Qi J, Liu D, Liu W, Li J. Analysis of ACE2 Gene-Encoded Proteins Across Mammalian Species. Front Vet Sci 2020; 7:457. [PMID: 32719819 PMCID: PMC7349190 DOI: 10.3389/fvets.2020.00457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/22/2020] [Indexed: 01/16/2023] Open
Abstract
Human beings are currently experiencing a serious public health event. Novel coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2), has infected about 3 million people worldwide and killed more than 200,000, most being the elderly or people with potential chronic diseases or in immunosuppressive states. According to big data analysis, there are many proteins homologous to or interacting with the angiotensin-converting enzyme 2 (ACE2), which, therefore, may not be the only receptor for the novel coronavirus; other receptors may also exist in host cells of different species. These potential receptors may also play an important role in the infection process of the novel coronavirus. The current study aimed to discover such key proteins or receptors and analyze the susceptibility of different animals to the novel coronavirus, in order to reveal the transmission process of the virus in cross-species infection. We analyzed the proteins coded by the ACE2 gene in different mammalian species and predicted their correlation and homology with the human ACE2 receptor. The major finding of our predictive analysis suggested ACE2 gene-encoded proteins to be highly homologous across mammals. Based on their high homology, their possibility of binding the spike-protein of SARS-CoV-2 is quite high and species such as Felis catus, Bos taurus, Rattus norvegicus etc. may be potential susceptible hosts; special monitoring is particularly required for livestock that are in close contact with humans. Our results might provide ideas for the prevention and control of the novel coronavirus pneumonia.
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Affiliation(s)
- Ying Cao
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China.,CAS Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China.,College of Animal Sciences and Veterinary Medicine, Guangxi University, Nanning, China
| | - Yeping Sun
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Xiaodong Tian
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Zhihua Bai
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Yue Gong
- National Science Library, Chinese Academy of Sciences, Beijing, China
| | - Jianxun Qi
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Di Liu
- CAS Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Wenjun Liu
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China.,Center for Biosafety Mega-Science, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Jing Li
- CAS Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
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Strafella C, Caputo V, Termine A, Barati S, Gambardella S, Borgiani P, Caltagirone C, Novelli G, Giardina E, Cascella R. Analysis of ACE2 Genetic Variability among Populations Highlights a Possible Link with COVID-19-Related Neurological Complications. Genes (Basel) 2020; 11:genes11070741. [PMID: 32635188 PMCID: PMC7397291 DOI: 10.3390/genes11070741] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/25/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023] Open
Abstract
Angiotensin-converting enzyme 2 (ACE2) has been recognized as the entry receptor of the novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). Structural and sequence variants in ACE2 gene may affect its expression in different tissues and determine a differential response to SARS-Cov-2 infection and the COVID-19-related phenotype. The present study investigated the genetic variability of ACE2 in terms of single nucleotide variants (SNVs), copy number variations (CNVs), and expression quantitative loci (eQTLs) in a cohort of 268 individuals representative of the general Italian population. The analysis identified five SNVs (rs35803318, rs41303171, rs774469453, rs773676270, and rs2285666) in the Italian cohort. Of them, rs35803318 and rs2285666 displayed a significant different frequency distribution in the Italian population with respect to worldwide population. The eQTLs analysis located in and targeting ACE2 revealed a high distribution of eQTL variants in different brain tissues, suggesting a possible link between ACE2 genetic variability and the neurological complications in patients with COVID-19. Further research is needed to clarify the possible relationship between ACE2 expression and the susceptibility to neurological complications in patients with COVID-19. In fact, patients at higher risk of neurological involvement may need different monitoring and treatment strategies in order to prevent severe, permanent brain injury.
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Affiliation(s)
- Claudia Strafella
- Medical Genetics Laboratory, Department of Biomedicine and Prevention, Tor Vergata University, 00133 Rome, Italy; (V.C.); (P.B.); (G.N.); (E.G.); (R.C.)
- Genomic Medicine Laboratory UILDM, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (A.T.); (S.B.)
- Correspondence:
| | - Valerio Caputo
- Medical Genetics Laboratory, Department of Biomedicine and Prevention, Tor Vergata University, 00133 Rome, Italy; (V.C.); (P.B.); (G.N.); (E.G.); (R.C.)
- Genomic Medicine Laboratory UILDM, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (A.T.); (S.B.)
| | - Andrea Termine
- Genomic Medicine Laboratory UILDM, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (A.T.); (S.B.)
| | - Shila Barati
- Genomic Medicine Laboratory UILDM, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (A.T.); (S.B.)
| | - Stefano Gambardella
- Neuromed Institute IRCCS, 86077 Pozzilli, Italy;
- Department of Biomolecular Sciences, University of Urbino “Carlo Bo”, 61029 Urbino, Italy
| | - Paola Borgiani
- Medical Genetics Laboratory, Department of Biomedicine and Prevention, Tor Vergata University, 00133 Rome, Italy; (V.C.); (P.B.); (G.N.); (E.G.); (R.C.)
| | - Carlo Caltagirone
- Department of Clinical and Behavioral Neurology, IRCCS Fondazione Santa Lucia, 00179 Rome, Italy;
| | - Giuseppe Novelli
- Medical Genetics Laboratory, Department of Biomedicine and Prevention, Tor Vergata University, 00133 Rome, Italy; (V.C.); (P.B.); (G.N.); (E.G.); (R.C.)
- Neuromed Institute IRCCS, 86077 Pozzilli, Italy;
| | - Emiliano Giardina
- Medical Genetics Laboratory, Department of Biomedicine and Prevention, Tor Vergata University, 00133 Rome, Italy; (V.C.); (P.B.); (G.N.); (E.G.); (R.C.)
- Genomic Medicine Laboratory UILDM, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (A.T.); (S.B.)
| | - Raffaella Cascella
- Medical Genetics Laboratory, Department of Biomedicine and Prevention, Tor Vergata University, 00133 Rome, Italy; (V.C.); (P.B.); (G.N.); (E.G.); (R.C.)
- Department of Biomedical Sciences, Catholic University Our Lady of Good Counsel, 1000 Tirana, Albania
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Fu J, Zhou B, Zhang L, Balaji KS, Wei C, Liu X, Chen H, Peng J, Fu J. Expressions and significances of the angiotensin-converting enzyme 2 gene, the receptor of SARS-CoV-2 for COVID-19. Mol Biol Rep. 2020;47:4383-4392. [PMID: 32410141 PMCID: PMC7224351 DOI: 10.1007/s11033-020-05478-4] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/28/2020] [Indexed: 12/28/2022]
Abstract
The ACE2 gene is a receptor of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) for COVID-19 (coronavirus disease 2019). To analyze the expression profiles and clinical significances for this gene in humans, RNA-seq data representing 27 different tissues were analyzed using NCBI; total RNA was extracted from different tissues of mouse and semi-quantitative reverse transcriptional-polymerase chain reaction (Q-RT-PCR) was carried out. Immunohistochemistry expression profiles in normal tissues and cancer tissues and TCGA survival analysis in renal and liver cancer were conducted. ACE2 was highly conserved in different species. In normal tissues, ACE2 expression distributions were organ-specific, mainly in the kidney, male testis and female breast, and cardiovascular and gastrointestinal systems. High level of expression in testis, cardiovascular and gastrointestinal system indicated that SARS-CoV-2 might not only attack the lungs, but also affect other organs, particularly the testes, thus it may severely damage male sexual development for younger male and lead to infertility in an adult male, if he contracted COVID-19. On the other side, high expression of ACE2 was correlated with increased survival rate in renal and liver cancer, indicating that ACE2 is a prognostic marker in both renal cancer and liver cancers. Thus, the ACE2 is a functional receptor for SARS-CoV-2 and has a potential anti-tumor role in cancer. Taken together, this study may not only provide potential clues for further medical pathogenesis of COVID-19 and male fertility, but also indicate the clinical significance of the role of the ACE2 gene in cancer.
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Wu X, Zhu B, Zou S, Shi J. The Association Between ACE2 Gene Polymorphism and the Stroke Recurrence in Chinese Population. J Stroke Cerebrovasc Dis 2018; 27:2770-2780. [PMID: 30056001 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/21/2018] [Accepted: 06/02/2018] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The angiotensin-converting enzyme 2 (ACE2) is closely associated with cardiovascular disease and cerebrovascular disease. Most studies on ACE2 gene polymorphism focused on its relations with cardiovascular disease, but there was a lack of research on its relations with stroke. Our study aimed to explore the association between 4 single-nucleotidepolymorphisms (SNPs) of ACE2 gene polymorphism and stroke recurrence. DESIGN AND PARTICIPANTS In our study, the case group included 125 stroke patients with recurrence and the control group included 153 patients without recurrence. Four SNPs (rs2106809, rs2285666, rs879922, and rs2074192) were genotyped by Ligase detection reaction. The association between stroke recurrence and SNPs were analyzed by multivariate logistic regression. RESULTS We find no association between ACE2 gene polymorphism and stroke recurrence. Haplotype A-G-C may associate with the stoke recurrence of male patients. The recurrence risk of male stroke patients with hypertension history and rs2285666-C allele is 2.82 times as high as that of those without hypertension history but with T allele. Among male stroke patients with hypertension history, the recurrence risk of those with rs2285666-C allele is 2.38 times as high as those with T allele; and the recurrence risk of those with rs2106809-A allele is 2.12 times as high as those with G allele. But those recurrence risks lose their statistical significance after adjustment for other factors. CONCLUSIONS We find no influence of ACE2 gene polymorphism on stroke recurrence and only find possible interaction between hypertension history and the ACE2 gene in male stroke patients.
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Affiliation(s)
- Xiaomei Wu
- Department of Clinical Epidemiology and Center of Evidence Based Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Bo Zhu
- Department of Cancer Prevention and Treatment, Cancer Hospital of China Medical University/Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Safeng Zou
- Department of Neurology and Rehabilitation Medicine, Dalian Municipal Central Hospital, Dalian, China
| | - Jingpu Shi
- Department of Clinical Epidemiology and Center of Evidence Based Medicine, The First Hospital of China Medical University, Shenyang, China.
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