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The geographic distribution of the ACE II genotype: A novel finding


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Angiotensin converting enzyme (ACE) gene polymorphism insertion (I) or deletion (D) has been widely studied in different populations, and linked to various functional effects and associated with common diseases. The purpose of the present study was to investigate the relationship between the ACE I/D frequency in different populations and geographic location; ACE I/D allele frequency in the Lebanese population and ACE II genotype contribution to the geographic trend were also identified. Five hundred and seventy healthy volunteers were recruited from the Lebanese population. Genomic DNA was extracted from buccal cells, and amplified by polymerase chain reaction; products were then identified by gel electrophoresis. The frequencies of the different ACE I/D genotypes were determined and tested for Hardy-Weinberg equilibrium (HWE). To assess the relationship between ACE I/D frequency and geographic location, and to identify how the Lebanese population contributes to the geographic trend in ACE I/D frequencies, Eurasian population samples and Asians were incorporated in the analyses from the literature. The frequency of the I allele in the Lebanese population was 27% and the corresponding II genotype was at a frequency of 7.37% (in HWE; P=0.979). The ACE I allele and genotype frequencies show an association with longitude, with frequencies increasing eastwards and westwards from the Middle East.
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The geographic distribution of the ACE II genotype:
a novel finding
*, P. R. G A R D
School of Pharmacy, Lebanese American University, Byblos, Lebanon
School of Pharmacy & Biomolecular Sciences, University of Brighton, Brighton BN2 4GJ, UK
(Received 8 August 2007 and in revised form 2 November 2007 )
Angiotensin converting enzyme (ACE) gene polymorphism insertion (I) or deletion (D) has been
widely studied in different populations, and linked to various functional effects and associated with
common diseases. The purpose of the present study was to investigate the relationship between the
ACE I/D frequency in different populations and geo graphic location; ACE I/D allele frequency
in the Lebanese population and ACE II genotype contribution to the geographic trend were also
identified. Five hundred and seventy healthy volunteers were recruited from the Lebanese
population. Genomic DNA was extracted from buccal cells, and amplified by polymerase chain
reaction; products were then identified by gel electrophoresis. The frequencies of the different ACE
I/D genotypes were determined and tested for Hardy–Weinberg equilibrium (HWE). To assess the
relationship between ACE I/D frequency and geographic location, and to identify how the Lebanese
population contributes to the geographic trend in ACE I/D frequencies, Eurasian population
samples and Asians were incorporated in the analyses from the literature. The frequency of the
I allele in the Lebanese populati on was 27% and the corresponding II genotype was at a frequency
of 7
37% (in HWE; P=0
979). The ACE I allele and genotype frequencies show an association with
longitude, with frequencies increasing eastwards and westwards from the Middle East.
1. Introduction
Angiotensin converting enzyme (ACE) is a
membrane-bound dipeptidyl carboxypeptidase ecto-
enzyme that is expressed both peripherally and in the
central nervous system. ACE is mainly responsible
for the production of angiotensin II, a potent vaso-
constrictor, and the inactivation of the potent vaso-
dilator bradykinin. Because of its broad-ranging
effects on vascular homeostasis, ACE has become
a candidate for association studies with common dis-
eases. The ACE gene maps to chromosome 17q23,
spans 21 kb, and comprises 26 exons and 25 introns
(Hubert et al., 1991); the GenBank accession number
is AC002345 or AF118569 (
To date, 259 polymorphisms have been reported in
the ACE gene ( , with the I/D
polymorphism, first reported by Rigat et al. (1990),
attracting the most interest. This I/D polymorphism is
defined by the presence (insertion; I) or absence (de-
letion; D) of a 287 base pair (bp) Alu repeat sequence
in intron 16 (Rieder et al., 1999). The ACE I/D poly-
morphism has been linked to various functional ef-
fects, for example the DD genotype being associated
with high plasma ACE levels in addition to numerous
diseases. One of the most extensively studied associa-
tions is with cardiovascular diseases, including myo-
cardial infarction (Cambien et al., 1992; Nakai et al.,
1994), left ventricular hypertrophy and dysfunction
(Schunkert et al., 1994), dilated cardiomyopathy
(Raynolds et al., 1993; Harn et al., 1995) hypertrophic
cardiomyopathy (Marian et al., 1993), carotid thick-
ening (Castellano et al., 1995; Kauma et al., 1996),
venous thrombosis (Philipp et al., 1998), nephropathy
* Corresponding author. School of Pharmacy, Lebanese American
University, Byblos, Lebanon, P. O. Box: 36 F 19. Telephone:
+961 9 547254 (ext. 2312). Fax:+961 9 547256. e-mail: ysaab@
Genet. Res., Camb. (2007), 89, pp. 259–267. f 2007 Cambridge University Press
doi:10.1017/S0016672307009019 Printed in the United Kingdom
(Schmidt & Ritz, 1997) and coronary restenosis after
stent implantation (Amant et al., 1997). Currently, the
best evidence for an association with the ACE I/D
polymorphism is with arterial hypertension in men
(Fornage et al., 1988 ; Higaki et al., 2000); one study
of male carriers of the DD genotype showed a 1
increase in risk (O’Donnell et al., 1998). It has also
been suggested that the ACE I/D polymorphism may
contribute to an individual’s susceptibility to affective
disorders and the onset of action of antidepressant
therapies (Arinami et al., 1996 ; Baghai et al., 2001,
2004, 2005; Gard et al., 2004 ; Saab et al., 2007 b).
The ACE DD genotype was also found to be a sig-
nificant risk factor for children with congenital
renal malformations going on to develop progressive
renal failure (Hohenfellner et al., 2001). Also, it
was found that in patients with lupus nephritis,
the ACE I/D genotype was associated with the se-
verity of the disease and a poor prognosis (Guan et al.,
Saab et al. (2004) have typed the ACE I/D gene
polymorphism in the Lebanese population, where
the homozygous II genotype accounted for 8 % of the
sample an incidence that was found to be atypi cally
low relative to European and East Asian populations.
These preliminary results suggested that the ACE II
genotype frequency might vary according to a geo-
graphic trend, as has been postulated for other Alu
insertion polymorphisms (Stoneking et al., 1997).
The objective of the present study was to determine
whether the ACE I/D gene polymorphism frequency
did indeed correlate with geographic distance and
then identify whether the ACE gene can be considered
as a genetic marker for the past demography of
human populations.
2. Materials and methods
(i) ACE genotype frequency determination
in Lebanese subjects
A total of 570 healthy volunteers were recruited from
the Lebanese population. Included were non-obese
subjects (body mass index (BMI) <29
) with
no history or clinical evidence of diabetes, cardio-
vascular problems, hypertension, renal insufficiency
and/or depression. All study subjects are of Lebanese
origin, and were living in Lebanon at the tim e of
study. Exclusion criteria were set to achieve parity
with other studies.
(ii) Sample collection and DNA extraction
Each volunteer was instructed to give a DNA sample
from the cheek using a cheek swab. The sample was
used for DNA extraction. DNA was extracted using
a protocol described by Saab et al. (2007b).
(iii) ACE I/D gene polymorphism genoty ping
The presence of the insertion/deletion allele in intron
16 of the ACE gene was detected using the method
of Rigat et al. (1990) with some modifications (Sery
et al., 2001). The sequence of the sense oligonucleo-
tide primer is 5k-CTG GAG ACC ACT CCC ATC
CTT TCT-3k and the antisense primer 5k-GAT GTG
GCC ATC ACA TTC GTC AGA T-3k. Polymerase
chain reaction was performed in a final volume of
25 ml containing 50 mM KCl, 10 mM Tris-HCl,
pH 8
4, 5 U/ml MgCl
5 mM of each dNTP, 0
Taq DNA polymerase, 0
2 mM of each primer, and
3 ml of DNA solut ion. PCR products were separated
and sized by electrophoresis on a 2
5% agarose gel
and visualized directly with ethidium bromide staining.
The insertion allele manifested as a 490 bp band, and
the deletion allele was visualized as a 190 bp band.
Because of the possibility of preferential amplification
of the D fragment in relation to the I fragment, re-
sulting in mistyping of I/D as DD genotype, all DD
genotypes were confirmed (Odawara et al., 1997).
(iv) ACE gene geographic mapping
We identified literature, published in English between
1984 and 2006, reporting ACE I/D gene polymor-
phisms. The extracted data are summarized and tabu-
lated in Table 2. Excluded were studies of a small
sample size (<48), studies where the subjects’ origins
were unknown and where subjects were known to be
suffering from a disease.
The exception was the Kuwait sample, which com-
prises 48 individuals suffering from nephropathy. This
sample was included due to the shortage of available
samples from the Middle East, but app ears to display
allele and genotype frequencies consistent with those
observed in the region. In addition, the genotypes did
not appear to be inconsistent with Hardy–Weinberg
(v) Statistical analysis
Statistical analyses were performed using SPSS
version 12 for Window s. The study samples’ allele
and genotype frequencies were estimated by the gene
counting method. The agreement with Hardy–
Weinberg equilibrium of the observed genotypic dis-
tribution for the ACE I/D alleles was tested using
Fisher exact tests. A P value of <0
05 was considered
statistically significant.
Genetic distances were estimated assuming that
differences in allele frequency distributions between
populations were due to drift. Pairwise distances were
calculated as d=ln (1 F
) (Weir, 1996). Nei’s
genetic distances (Nei & Feldman, 1972) were also
calculated for the purpose of constructing neighbour-
joining trees (Saitou & Nei, 1987) using the
Y. B. Saab et al. 260
3.65 (Felsenstein, 1993) and the genetic data analysis
package GDA (Lewis & Zaykin, 2001). In most cases,
specific geographic locations relating to the samples
were not specified in the literature, so geographic
distances were taken as pairwise distances (in kilo-
metres) betw een capital cities of the country in ques-
tion. To identify whether any co rrelation exists
between the two matrices (genetic and geographic
distances), a Mantel test was performed (10 000 per-
mutations, using the Pearson correlation coefficient)
using XLSTAT (Kovach Computing Services, 2007).
3. Results
(i) Subjects’ demog raphic characteristics
A total of 570 Lebanese subjects were included in the
study, which aimed to determine the ACE gene I/D
polymorphism prevalence in the Lebanese popu-
lation. The study samples con sisted of 51
9% and
1% males and females, respectively. The mean age
was 28
63 years (range 18–69 years) and the average
BMI was 23
04 kg/m
(range 17
41 kg/m
(ii) ACE genotype distribution in Lebanese and
Hardy–Weinberg equilibrium
The detailed distribution of the ACE genotypes in the
Lebanese population is depicted in Table 1. The
prevalence of the D allele was 73%, and the II geno-
type accounted for 7
37%. Genotype frequencies
were found to be in Hardy–Weinberg equilibrium
743, Fisher exact test, 10 000 permutations).
(iii) ACE II genotype prevalence among different
The ACE allele frequencies of different populations
retrieved from the literature, along with that of this
study’s finding, are depicted in Table 2. The results
suggest that the ACE II genotype frequency decreas es
according to a geographic trend from northern
Europe to southern Europe, and on to the Medi-
terranean region. Moreover, moving geographically
eastward, the II genotype prevalence appears to
increase progressively. The results of the Mantel test
show a reasonable and significant correlation between
geographic and genetic distances between the popu-
lations (r=0
478984, P<0
0001). On further analysis,
it appears that this is largely influenced by II fre-
quency and longitude correlation (R
727), where
the II genotype frequency declines on moving from
Europe to the Middle East, followed by an increase
moving eastwards to Asia (Fig. 1). There was no
meaningful relationship between II genotype fre-
quency and latitude (R
027). For the correlation
with longitude, the quadratic relationship proved
to be more significant than the linear relationship
(starting with a GLM maximal model: II frequency=
, where x is the degrees east of
Greenwich, UK and the b parameters were estimated
by maximum likelihood; removing the quadratic
term resulted in a significant difference between the
deviance values of the two models (Crawley, 1993),
where P=0
0001). The correlation between I allele
frequency and longitude gave a slightly weaker re-
lationship than that with the II gen otype (R
In brief, the II genotype had an average frequency of
23% in northern Europe, 20% in the UK, 15 % in
Spain, 14 % in north Italy, 12 % in south Italy, 7% in
Lebanon, 6% in the United Arab Emirates (UAE),
2% in Kuwait, and then an average of 35 % in China
and 45% in Japan.
Fig. 2 shows the neighbour-joinin g tree relating all
36 population samples using Nei’s genetic distance
(Nei & Feldman, 1972). Because the ancestral state of
the Alu insertion polymorphisms is considered to be
the absence of the insertion, the tree could be rooted
using a hypothetical outgroup consisting of individ-
uals fixed for the D allele. The multiple popul ation
samples of identical country of origin were averaged
to condense the tree.
4. Discussion
(i) ACE I/D genotype distribution
According to a meta-analysis of 145 studies with
49 959 subjects, the overall prevalence of the D allele
Table 1. ACE I/D observed genotypes/allele frequencies in the Lebanese
population compared with expected genotypes
N (%)
N (%)
II 42 (7
37) I: 0
27 41 (7
29) 0
ID 219 (38
42) D: 0
73 225 (39
DD 309 (54
21) 304 (53
All 570 (100) 570 (100)
The geographic distribution of the ACE II genotype: a novel finding 261
was 54
0%. The II, ID and DD genotype fre-
quencies were 22
5%, 47
0% and 30
5%, respectively
(Staessen et al., 1997). Ethnicity was a major deter-
minant of the D and I allele frequencies as the preva-
lence of the D allele was 39
1% in Asians, 56
2% in
Caucasians and 60
3% in blacks (Staessen et al.,
1997). In the present study, the D allele had a fre-
quency of 73
42%, which is consistent with the other
two Middle Eastern populations (Kuwait and UAE)
in being amongst the highest recorded.
(ii) ACE I/D gene polymorphism: a genetic marker
The average ACE II genotype frequency in control
subjects in different populations of different countries
was thoroughly examined and compared. Never-
theless, we accept that the comparison of the allele
and genotype frequencies with other published
studies has to be considered with some caution since
Table 2. ACE II genotype frequency in different populations/countries
Country Study authors
Year of
No. of
frequency (%)
Sweden Kurland et al. 2001 59 27
Denmark Bladbjerg et al. 1999 199 23
United Kingdom Kehoe et al. 1999 386 23
United Kingdom Steeds et al. 2001 507 22
United Kingdom Narain et al. 2000 342 18
Netherland Hosoi et al. 1996 61 20
Hungary Barkai et al. 2005 120 27
Belgium Gu et al. 1994 109 19
Germany Ebert et al. 2005 145 23
Germany Filler et al. 2001 200 18
France Blanche et al. 2001 560 18
France Girerd et al. 1998 340 17
Spain Alvarez et al. 1999 400 15
Spain Coll et al. 2003 133 15
Italy Di Pasquale et al. 2005 684 18
Italy Panza et al. 2002 252 13
Turkey Tanriverdi et al. 2005 102 24
Turkey Serdaroglu et al. 2005 287 22
Turkey Bedir et al. 1999 143 13
Lebanon Saab et al. Current Study 570 7
Kuwait Al-Eisa et al. 2001 48 2
United Arab Emirates Saeed et al. 2005 130 6
India Patil et al. 2005 300 26
China Thomas et al. 2001 119 33
China Ohishi et al. 1994 175 37
China Young et al. 1998 183 39
China Iwai et al. 1994 122 41
China Yan et al. 2005 352 41
Korea Ryu et al. 2002 167 34
Korea Um et al. 2003 613 37
Taiwan Lee & Tsai 2002 750 47
Japan Katoh et al. 2005 270 41
Japan Odawara et al. 1997 248 42
Japan Mannami et al. 2001 3657 43
Japan Maguchi et al. 1996 84 48
Japan Ishigami et al. 1995 87 51
0 50 100 150
East Coordinates
II Genotype Frequency
Fig. 1. Plot of ACE II genotype frequencies and
coordinates east of Greenwich, UK. For the linear
relationship R
599; for the quadratic, R
The Lebanese population is circled.
Y. B. Saab et al. 262
published data might have been generated using
slightly diff erent methodologies, and thus there is a
possibility of discrepancies in genotype classification
(Ueda et al., 1996) in particular, since some geno-
typing methodologies misclassify ID heterozygotes
as DD homozygotes. Although such a misclassi-
fication can result in deviations from Hardy–
Weinberg equilib rium, which was not observed in our
study, it was considered prudent to base our analysis
on the II genotype frequencies in addition to the
I allele frequencies. Indeed, it may be for this reason
that the stronger correlation with longitude was
observed with the genotype data than the allele fre-
quency scores.
Genetic polymorphisms have often been found to
show geographic clines, many of which have been put
to great use in offering insights into the historical
movements of peoples around the globe since at least
as far back as Neolithic times (Cavalli-Sforza et al.,
1993; Barbujani et al., 1998). Such interpretations
of clines are not without their critics (e.g. Richards &
Sykes, 1998) and care is required not to over-interpret
geographic patterns when they emerge. In particular,
little confidence can be placed in the timing of popu-
lation movement. Broader conclusions, such as iden-
tifying the origin of a particular polymorphism on the
basis of its relative frequency, are less controversial;
and this is more so with Alu elements, which are
considered to be highly stable polymorphisms, where
deletion of newly inserted elements is a rare event
(Stoneking et al., 1997). Low frequencies of the
insertion are therefore indicative of the ancestral
state, and African populations tend to have not only
the lowest frequency of the insertion (Bayoumi et al.,
2006) but also the greatest variation in frequen cy
(Stoneking et al., 1997). On this basis it would appear
that the ALU deletion within the ACE gene was,
of the populations studied here, Middle Eastern in
origin. Given that the human migration out of Africa
is likely to have journeyed through the Middle East
before migrating east and west, it is to be expected
that the Lebanese population should be ancestral
with regard to the ACE polymorphism and to have
a relatively lower frequency of the insertion allele ;
this is borne out in the frequency–coordinate corre-
lation analysis in Fig. 1, where a significant quadratic
relationship was observed between both the I allele
frequency (not shown) and II genotype frequency and
the coordinates east of Greenwich, UK. The picture is
less clear in the tree reconstruction in Fig. 2. Although
the Middle Eastern populations appear quite distinct
from both European and Asian populations, these
latter groups are not well resolved, most likely due to
the fact that only a single locus has been investigated
for these populations.
In the analysis of modern human origins, genetic
maps demonstrating allelic clines have been quite
revealing. Classical attempts to distinguish distinct
ancestries of human subgroups (Cavalli-Sforza et al.,
1996) have been quite succ essful in employing classi-
cal genetic markers, such as the different gene fre-
quencies of A and B blood antigens. Consequently,
ABO blood groups have been used as a genetic
marker to differentiate human subgroups, on the
basis of their distinct demographic histories. It is also
considered that the frequency of an allele is likely to
be higher at its place of origin as well as in the region
where selective factors favour it. ABO gene fre-
quencies again offer an example of a gene that follows
this trend (Cavalli-Sforza et al., 1996). The gradient
of decreasing frequencies has also been shown with
haplotypes V and VI (Lucotte et al., 2001). Mapping
ACE I/D polymorphism genotype frequencies from
both this study and those of other authors on to a
geographic map, shows the ACE gene to have a geo-
graphic trend of expansion consistent with what is
known about the migration of modern Hom o sapiens
out of Africa, thus qualifying the ACE gene as
another useful marker tool for studying prehistoric
human demography. It remains to be seen, however,
whether disorders associated with the ACE gene
show geographic trends corresponding with the major
polymorphisms, including the Alu I/D.
Fig. 2. Neighbour-joining tree of population relationships.
The tree is rooted by a hypothetical ancestral population
fixed for the ACE D allele. UAE, United Arab Emirates.
The geographic distribution of the ACE II genotype: a novel finding 263
5. Conclusion
In summary, in view of the reported associations of
ACE gene polymorphisms and different diseases,
ACE genotypes were assessed in the Leba nese popu-
lation. The II genotype frequency was 7
37%. Com-
paring this study’s finding with that of other studies
in different populations, the ACE gene can be con-
sidered a useful genetic marker for gaining an insight
into the historical migrations of human populations,
in particular the frequency cline of the wild-type D
allele. Future pharmacogenetic studies are likely to
reveal the natural selection for this gene’s geographic
variation and the pharmacological role of this enzyme
in different populations.
We acknowledge the Lebanese American University (LAU)
for funding the project. We thank Dr Hussam Atat,
Mr Bechara Mfarej and LAU Pharm D graduates of 2004
and 2005 for their assistance in the sample collection and
laboratory work.
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The geographic distribution of the ACE II genotype: a novel finding 267
... and a II genotype frequency of 7.8% in controls ( Table 1). These numbers are in line with the literature stating that the I allele is least common in Caucasians and Middle Easterners, and most common in Asians [Supplementary Table 1; (24,27)]. ...
... These results suggest that genotyping for ACE1 I/D polymorphism could be used to assess risk and predict severity for better prognosis and management of the disease. This is especially important for Middle Easterners in general and the Lebanese in particular who, and similarly to the results of the current study, have a higher frequency of the ACE1 D allele when compared to the I allele (24,25). ...
Full-text available
Background: Individuals infected with the COVID-19 virus present with different symptoms of varying severity. In addition, not all individuals are infected despite exposure. Risk factors such as age, sex, and comorbidities play a major role in this variability; however, genetics may also be important in driving the differences in the incidence and prognosis of the disease. An Insertion/Deletion ( I/D ) polymorphism in the ACE1 gene (rs1799752) may explain these genetic differences. The aims of this study were to determine the potential role of ACE1 I/D genetic polymorphism in the risk of contracting COVID-19 as well as predicting the severity of COVID-19 infection. Methods: Three-hundred and eighty-seven non-related Lebanese subjects, 155 controls and 232 cases, who presented to the American University of Beirut Medical Center (AUBMC) for COVID-19 PCR testing were recruited. Clinical data were collected via filling a questionnaire and accessing the medical records. Peripheral blood was withdrawn for DNA isolation, and genotyping performed with standard PCR followed by band visualization on agarose gel. Results: In our study population, previously described risk factors such as gender, age, and comorbidities were associated with increase in disease susceptibility and severity. ACE1 I was the least common allele, and there was a positive association between ACE1 I and the risk of contracting the COVID-19 disease. More specifically, the frequency of II genotype was significantly higher among cases when compared to controls ( P = 0.035) with individuals with the II genotype having greater risk for contracting the COVID-19 disease: OR = 2.074, P = 0.048 in the multivariate analysis. As for disease severity, the DD genotype and D allele were associated with increased risk for developing severe symptoms (OR = 2.845, P = 0.026 and OR = 2.359, P = 0.014, respectively), and the DD genotype with necessitating hospitalization (OR = 2.307, P = 0.042). In parallel, D allele carriers showed a significantly increased risk for developing hypoxia: OR = 4.374, P = 0.045. Conclusion: We found a positive association between ACE1 I and the risk of contracting the COVID-19 disease, and between ACE1 D and a worse outcome of the COVID-19 infection. Therefore, genotyping for ACE1 I/D polymorphism could be used to assess risk and predict severity for better prognosis and management of the disease.
... Likewise, populations of Italy, Spain and France have D allele frequencies reaching 87%. In contrast, in Eastern Asian populations (Korean, Chinese, Taiwanese and Japanese) a higher frequency of ACE I/I genotype was recorded compared to European populations (33% to 51% versus 13% to 27%), which could explain the high COVID-19 fatality in European patients (especially among Spanish, Italian and French) [77]. These findings also conformed to those found by Hatami et al., in which a higher frequency of the I allele was observed in China and Korea, while in European populations such as Germany, Italy and France, a higher frequency of the D allele was recorded [68]. ...
... Among others, the K26R ACE2 altering variant could potentially decrease or increase the ACE2/S-protein binding affinity and thus alter the viral ability to infect host cells. Moreover, the ACE2 C-terminal collectrin-like domain variant (N720D) affects the TMPRSS2-ACE2 complex and favors TMPRSS2 binding as well as its cleavage, thus helping it bind to S-protein and promoting viral entry [77]. It has been shown by molecular docking simulations that six ACE2 variants (T55A, E75G, I21T, K26R, A25T and E37K) increased the binding affinity of ACE2 to S-protein RBD, while 11 other variants (I21V, K26E, M82I, E35K, T27A, Y50F, N51D, S43R, K68E, E23K, and N58H) decreased it [87]. ...
Full-text available
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), has first been identified in Eastern Asia (Wuhan, China) in December 2019. The virus has then spread to Europe and across all continents where it has led to higher mortality and morbidity, and was declared as a pandemic by the World Health Organization (WHO) in March 2020. Recently, different vaccines have been produced and seem to be more or less effective in protecting from COVID-19. The renin-angiotensin system (RAS), an essential enzymatic cascade involved in maintaining blood pressure and electrolyte balance, is involved in the pathogenicity of COVID-19 since the angiotensin-converting enzyme II (ACE2) acts as the cellular receptor for SARS-CoV-2 in many human tissues and organs. In fact, the viral entrance promotes a downregulation of ACE2 followed by RAS balance dysregulation and an overactivation of the angiotensin II (Ang II)-angiotensin II type I receptor (AT1R) axis which is characterized by a strong vasoconstriction and the induction of the profibrotic, proapoptotic and proinflammatory signalizations in lungs and other organs. This mechanism is featured by a massive cytokine storm, hypercoagulation, an acute respiratory distress syndrome (ARDS), and a subsequent multiple organ damage. While all individuals are vulnerable to the SARS-CoV-2, the disease outcome and severity differ among people and countries and depends on a dual interaction between the virus and the host affected. Many studies have already pointed out the importance of host genetic polymorphisms (especially in the RAS) as well as other related factors such age, gender, lifestyle and habits, and underlying pathologies or comorbidities (diabetes and cardiovascular diseases) that could render individuals at higher risk of infection and pathogenicity. In this review, we explore the correlation between all these risk factors as well as how and why could they account for the severe post-COVID-19 complications.
... Currently, there is no definite and/or effective treatment for COVID-19 [5]. Sun et al. in their latest publication expressed the possible interaction of COVID-19 and ACE2 which may result in the degradation of ACE2, and the blockage of the pathway to the receptor by ACE2/Ang (1-7)/Mas receptor [6]. The angiotensin-converting enzyme inhibitors have been proposed as probable beneficial treatments for COVID-19, insinuating the RAS system as an important target for the treatment of lung diseases [5]. ...
... Similar to our report, Saab et al. examined the average ACE II genotype frequency in healthy subjects in different populations of different countries [6]. They disclosed that ACE I allele and genotype frequencies show an association with longitude. ...
Full-text available
With the emergence of the Novel Coronavirus (2019-nCoV), researchers worldwide have started detecting the probable pathogenesis of the disease. The renin-angiotensin system (RAS) and angiotensin-converting enzymes have received a good deal of attention as possible pathways involved in 2019-nCoV pathogenesis. As the experiments seeking to find potential medications acting on these pathways are being conducted in the early phases, having an ecological worldview on the relationship between the prevalence of COVID-19 disease and the genetic differences in the genes involved in the RAS system could be valuable for the field. In this regard, we conducted a meta-analysis study of the prevalence of ACE (I/D) genotype in countries most affected by the COVID-19. In the meta-analysis, 48,758 healthy subjects from 30 different countries were evaluated in 116 studies, using the Comprehensive Meta-analysis software. The I/D allele frequency ratio was pooled by a random-effect model. The COVID-19 prevalence data of death and recovery rates were evaluated as the latitudes for the meta-regression analysis. Our results demonstrated that with the increase of the I/D allele frequency ratio, the recovery rate significantly increased (point estimate: 0.48, CI 95%: 0.05-0.91, p = 0.027). However, there was no significant difference in the case of death rate (point estimate: 1.74, CI 95%: 4.5-1.04, p = 0.22). This ecological perspective coupled with many limitations does not provide a direct clinical relevance between the COVID-19 and RAS system, but it shows potential pathophysiological associations. Our results raise concerns about ethnic and genetic differences that could affect the effectiveness of the currently investigated RAS-associated medications in different regions.
... The deviation of the HWE was established using a χ 2 goodness-of-fit test with 1 • of freedom (df) except for the SNP in ACE2 rs2285666 located in the X chromosome, for which HWE was determined using the R package "HWadmiX" (32). Allelic frequencies obtained from the study were compared to other populations using the χ 2 and Fisher's exact test statistics (21,26,(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46). p-values <0.05 were considered statistically significant. ...
Full-text available
Genetic and non-genetic factors are responsible for the high interindividual variability in the response to SARS-CoV-2. Although numerous genetic polymorphisms have been identified as risk factors for severe COVID-19, these remain understudied in Latin-American populations. This study evaluated the association of non-genetic factors and three polymorphisms: ACE rs4646994, ACE2 rs2285666, and LZTFL1 rs11385942, with COVID severity and long-term symptoms by using a case-control design. The control group was composed of asymptomatic/mild cases (n = 61) recruited from a private laboratory, while the case group was composed of severe/critical patients (n = 63) hospitalized in the Hospital Universitario Mayor-Méderi, both institutions located in Bogotá, Colombia. Clinical follow up and exhaustive revision of medical records allowed us to assess non-genetic factors. Genotypification of the polymorphism of interest was performed by amplicon size analysis and Sanger sequencing. In agreement with previous reports, we found a statistically significant association between age, male sex, and comorbidities, such as hypertension and type 2 diabetes mellitus (T2DM), and worst outcomes. We identified the polymorphism LZTFL1 rs11385942 as an important risk factor for hospitalization (p < 0.01; OR = 5.73; 95% CI = 1.2–26.5, under the allelic test). Furthermore, long-term symptoms were common among the studied population and associated with disease severity. No association between the polymorphisms examined and long-term symptoms was found. Comparison of allelic frequencies with other populations revealed significant differences for the three polymorphisms investigated. Finally, we used the statistically significant genetic and non-genetic variables to develop a predictive logistic regression model, which was implemented in a Shiny web application. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC = 0.86; 95% confidence interval 0.79–0.93). These results suggest that LZTFL1 rs11385942 may be a potential biomarker for COVID-19 severity in addition to conventional non-genetic risk factors. A better understanding of the impact of these genetic risk factors may be useful to prioritize high-risk individuals and decrease the morbimortality caused by SARS-CoV2 and future pandemics.
... The ACE gene consists of two variant alleles that are insertion and deletion, in short, I and D, polymorphisms [48]. There are 03 distinct ACE genotypes; II, ID, and DD [49]. Discrepancies in spread, severity, and mortality in COVID-19 could be attributed to ...
... The ACE gene consists of two variant alleles that are insertion and deletion, in short, I and D, polymorphisms [48]. There are 03 distinct ACE genotypes; II, ID, and DD [49]. Discrepancies in spread, severity, and mortality in COVID-19 could be attributed to ...
... Evolutionary adaptive changes such as variants of the ACE2 receptor, which is used by the coronavirus and malaria to infect cells, may protect populations from SARS-CoV-2 in malaria endemic regions [23]. Wide use of chloroquine and its derivative (hydroxychloroquine) in the prevention and treatment of malaria in sub-Saharan Africa may have also contributed to the protection against SARS-CoV-2 infection [24]. The mechanisms of action of these drugs include interfering in the glycosylation process of cellular receptors of coronavirus and increasing the endosomal pH thus inhibiting the fusion of the virus on the cells [25]. ...
... Geographic distribution of ACE I (insertion in intron 16) allele was summarized by Saab et al. and its frequency increases eastwards and westwards from the Middle East [24]. The genetic polymorphism of ACE2 gene is well known world over with racial and ethnic variations [25,26] having varying influences on the altered functions of RAAS pathway [27]. ...
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Background: The ongoing outbreak of SARS-CoV-2 represents a significant challenge to international health. Several reports have highlighted the importance of ACE2 on the pathogenesis of COVID-19. The spike protein of SARS-CoV-2 efficiently binds to the angiotensin-converting enzyme 2 (ACE2) receptors and facilitates virus entry into the host cell. In the present study, we hypothesize that a functional insertion/deletion polymorphism-rs4646994 I/D and rs4240157 T > C in the ACE gene could be associated with SARS-CoV-2 infection and mortality. Methodology: This study included 117 consecutive COVID-19 patients and 150 age matched healthy controls (ACE2-rs4646994 I/D) and 100 age matched healthy controls with ACE2 rs4240157 T > C. We used Mutation specific PCR (MSP) for ACE2-rs4646994 I/D genotyping and amplification refractory mutation system (ARMS-PCR) for ACE2 rs4240157 T > C genotyping. Results: Results indicated that there were significant differences in the genotype distributions of ACE2-rs4646994 I/D polymorphisms (p < 0.030) and ACE2 rs4240157 T > C between COVID-19 patients and controls (p-values < 0.05). Higher frequency of DD genotype (48.71%) and D allele (0.67) was reported in COVID-19 patients than controls. Our results showed that the ACE2-DD genotype was strongly associated with increased COVID-19 severity (OR 2.37 (95%) CI = (1.19-4.70), RR = 1.39 (1.09-1.77), p < 0.013) and also a strong association was seen with ACE2-ID genotype with COVID-19 severity (OR 2.20 (95%) CI = (1.08-4.46), p < 0.020) in the codominant model. In allelic comparison, the D allele was strongly associated with COVID-19 severity (OR 1.58 (95% CI) (1.11-2.27), RR 1.21 (1.05-1.41) p < 0.010). A significant correlation of ACE2-I/D genotypes was reported with Age (p < 0.035), T2D (p < 0.0013), hypertension (p < 0.0031) and coronary artery disease (p < 0.0001). Our results indicated ACE2-DD genotype was strongly associated with increased COVID-19 mortality (OR 8.25 (95%) CI = (2.40 to 28.34), p < 0.008) and also ACE2-DD + DI genotype was strongly associated with increased COVID-19 mortality with OR 4.74 (95%) CI = (1.5214 to 14.7915), p < 0.007. A significant correlation was reported between COVID-19 patients and age matched controls (p < 0.0007). Higher frequency of heterozygosity TC (40%) followed by ACE2-CC genotype (24.78%) was reported among COVID-19 patients. Using multivariate analysis, ACE2-CT genotype was strong associated with SARS-CoV-2 severity with an OR 2.18 (95% CI) (1.92-3.99), p < 0.010 and also ACE2-CC genotype was linked with COVID-19 severity with an OR 2.66 (95% CI) (1.53-4.62), p < 0.005. A significant correlation of ACE2-T > C genotypes was reported with gender (p < 0.04), T2D (p < 0.035). ACE2-CC genotype was strongly associated with increased COVID-19 mortality OR 3.66 (95%) CI = (1.34 to 9.97), p < 0.011 and also ACE2-C allele was associated with COVID-19 mortality OR 2, 01 (1.1761-3.45), p < 0.010. Conclusions: It is concluded that ACE-DD genotype and D allele was strongly associated with increased COVID-19 patient severity. In addition, ACE I/D polymorphism were strongly associated with advanced age, diabetes and ischemic heart disease in COVID-19 patients whereas ACE-II genotype was a protective factor against the development of severe COVID-19. ACE2-DD genotype was strongly associated with increased COVID-19 mortality. Additionally, ACE2-CC and CT genotypes were strongly associated with COVID-19 severity. Therefore, our study might be useful for identifying the susceptible population groups for targeted interventions and for making relevant public health policy decisions.
... It will be interesting to investigate the possibility that DD genotype individuals are more resistant to viral infection initially but that the symptoms become more severe once infected as compared to those with ACE1 II genotype. However, this theory does not well explain the low SARS-CoV-2 infection rate in East Asia, where the frequency of II is much higher than in other areas, such as Europe and the Middle East [1,54]. ...
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The renin–angiotensin–aldosterone system (RAAS) appears to play an important role in SARS-CoV-2 infection. Polymorphisms within the genes that control this enzymatic system are candidates for elucidating the pathogenesis of COVID-19, since COVID-19 is not only a pulmonary disease but also affects many organs and systems throughout the body in multiple ways. Most striking is the fact that ACE2, one of the major components of the RAAS, is a prerequisite for SARS-COV-2 infection. Recently, we and other groups reported an association between a polymorphism of the ACE1 gene (a homolog of ACE2) and the phenotypic expression of COVID-19, particularly in its severity. The ethnic difference in ACE1 insertion (I)/deletion (D) polymorphism seems to explain the apparent difference in mortality between the West and East Asia. The purpose of this review was to further evaluate the evidence linking ACE1 polymorphisms to COVID-19. We searched the Medline database (2019–2021) for reference citations of relevant articles and selected studies on the clinical outcome of COVID-19 related to ACE1 I/D polymorphism. Although the numbers of patients are not large enough yet, most available evidence supports the notion that the DD genotype adversely influences COVID-19 symptoms. Surprisingly, small studies conducted in several countries yielded opposite results, suggesting that the ACE1 II genotype is a risk factor. This contradictory result may be the case in certain geographic areas, especially in subgroups of patients. It may also be due to interactions with other genes or to yet unexplained biochemical mechanisms. According to our hypothesis, such candidates are genes that are functionally involved in the pathophysiology of COVID-19, can act in concert with the ACE1 DD genotype, and that show differences in their frequency between the West and East Asia. For this, we conducted research focusing on Alu-related genes. The current study on the ACE1 genotype will provide potentially new clues to the pathogenesis, treatment, and diagnosis of SARS-CoV-2 infections.
The lungs are the primary target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, with severe hypoxia being the cause of death in the most critical cases. Coronavirus disease 2019 (COVID-19) is extremely heterogeneous in terms of severity, clinical phenotype and, importantly, global distribution. Although the majority of affected patients recover from the acute infection, many continue to suffer from late sequelae affecting various organs, including the lungs. The role of the pulmonary vascular system during the acute and chronic stages of COVID-19 has not been adequately studied. A thorough understanding of the origins and dynamic behaviour of the SARS-CoV-2 virus and the potential causes of heterogeneity in COVID-19 is essential for anticipating and treating the disease, in both the acute and the chronic stages, including the development of chronic pulmonary hypertension. Both COVID-19 and chronic pulmonary hypertension have assumed global dimensions, with potential complex interactions. In this Review, we present an update on the origins and behaviour of the SARS-CoV-2 virus and discuss the potential causes of the heterogeneity of COVID-19. In addition, we summarize the pathobiology of COVID-19, with an emphasis on the role of the pulmonary vasculature, both in the acute stage and in terms of the potential for developing chronic pulmonary hypertension. We hope that the information presented in this Review will help in the development of strategies for the prevention and treatment of the continuing COVID-19 pandemic.
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Background: An increasing number of studies with conflicting results regarding the association between angiotensin-converting enzyme (ACE) gene deletion polymorphism and cardiovascular disease has recently been published. The present prospective long-term study was conducted to evaluate whether the DD genotype could also be associated with a higher prevalence of hypertension in healthy subjects over 6 years of follow-up. We also investigated the effects of the ACE-I/D genotypes on diastolic function by echocardiography in healthy subjects without any risk factors and any events after 6 years of follow-up. Methods: Population: 684 healthy volunteers (aged 25-55 years) normotensive and free of cardiovascular diseases, with acceptable echocardiographic window were enrolled. All subjects had to have a normal electrocardiogram (ECG) and echocardiogram (ECHO) at entry. All subjects have undergone a complete physical examination, 12-lead ECG and ECHO; DNA analysis and serum cholesterol have been performed on venous blood samples. All subjects underwent a clinical evaluation each year for the 6-year duration of the study. In addition, 275 subjects without any risk factors underwent an ECHO every year of the follow-up, to check the influence of genotypes on myocardial diastolic performances. Results: All 684 subjects completed 6 years of follow-up. We obtained 3 genetically distinct groups: I) the ACE-DD group (n = 225, 80 F/ 145 M, mean age 43.4 +/- 7.6 years) with 42 hypertensive subjects (18.3%), 5 heart failure (HF) subjects and 6 subjects with acute coronary syndromes (ACS). There was no association between family history, smoking habit, hypercholesterolaemia and events. 2) the ACE-ID group (n = 335, 116 F/2 19 M, mean age 43.6 +/- 7 years) with 16 hypertensive subjects (4.7%) and 3 subjects with ACS. 3) the ACE-II group (n = 124, 45 F/79 M, mean age 42.5 +/- 6.9 years) with 2 hypertensive subjects (1.6%) and I HF subject. The incidence of hypertension and cardiovascular events, was significantly higher in the ACE-DD (53 cases, 23%) than in the ACE-ID and ACE-II groups (20 and 3 cases, 5.9% and 2.4%, respectively), p = 0.0001. The higher incidence of hypertension was observed in the older age groups (36-45 and 46-55 years) with ACE-DD and ACE-ID genotypes. Moreover, ACE-DD significantly and early affected myocardial diastolic properties in the total group examined, also when stratified for age. There was a reduction of E/A ratio and it was more evident in subjects aged 36-45 and 46-55 years, p = 0.0001. Conclusion: Our data suggest that ACE-DD polymorphism is associated with a higher incidence of hypertension in baseline healthy subjects, irrespective of other risk factors, and appears to affect the diastolic function. These effects were apparent predominantly in the older age groups.
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Studies in various ethnic groups have shown contradictory evidence on the association of the angiotensin converting enzyme (ACE) insertion/deletion (I/D) polymorphism with essential hypertension. We conducted a case-control study in Samsun, Turkey, to examine the association between ACE genotype, ACE serum activity, and blood pressure. Serum ACE activity was measured and ACE I/D polymorphism performed in 165 hypertensive and 143 normotensive subjects. Genomic DNA was extracted from blood samples and amplified by polymerase chain reaction (PCR). PCR primers were flanking the polymorphic region in intron 16 of the ACE gene. The distribution of the DD, ID, and II ACE genotypes was 65, 77, and 23 in hypertensive patients and 42, 82, and 19 in normotensive subjects (P > .05). The estimated frequency of the insertion allele was 0.37 in hypertensive and 0.42 in normotensive subjects. Nevertheless, sensitivity analysis, based on positive family history and severity of hypertension, suggested that significant associations existed between more homogeneous groups of hypertensives and normotensives (P < .05). ACE genotype influenced ACE activity and the highest level was in DD genotype, being the lowest in II genotype. ACE serum levels were significantly higher in hypertensives as compared with normotensives (P < .01). A modest correlation was observed between blood pressure and ACE among hypertensive persons (r = 0.25, P < .05) and this did persist in multivariate analysis (P < .05 for systolic blood pressure and P < .005 for diastolic blood pressure). These data suggest that ACE DD genotype may have predisposing effects on severe hypertensives and cases with positive family history, and that ACE may be one of the independent factors on hypertension.Keywords: Angiotensin converting enzyme; genotype; blood pressure
The angiotensin converting enzyme gene (ACE) is of much interest as a candidate gene conferring an individual's genetic susceptibility to left ventricular hypertrophy (LVH). LVH has long been thought to be an end point of essential hypertension (EH), rather than a separate entity, though it is influenced by a unique set of hormonal, vascular and genetic factors. In this study, we attempted to determine whether two representative polymorphisms of the ACE gene, ACE I/D and 2350 G > A, known to be associated with EH and to have a highly significant influence on plasma ACE levels, could implicate ACE as a quantitative trait locus (QTL) for LVH. We carried out a retrospective, case-control study of the two ACE polymorphisms amongst 180 nationals (50 LVH patients and 130 controls) from the United Arab Emirates (Emirati)-an ethnic group characterized by an absence of alcohol intake and cigarette smoking-for putative correlations with LVH. Clinical diagnoses of LVH were based on echocardiographic and ECG criteria. ACE I/D and 2350 G > A genotypes were determined by polymerase chain reaction (PCR) and restriction digestion. Univariate and multivariate logistic regression analyses revealed an association between ACE polymorphisms and LVH. Haplotype analysis further supported this finding. The ACE I/D and ACE 2350 G > A polymorphisms were in strong linkage disequilibrium and were independently associated with LVH, suggesting that ACE is likely to be a QTL for LVH. In conclusion, This is the first association study of the ACE 2350 G > A polymorphism with LVH; the results showed that this polymorphism, along with ACE I/D, is associated with LVH.
A new method called the neighbor-joining method is proposed for reconstructing phylogenetic trees from evolutionary distance data. The principle of this method is to find pairs of operational taxonomic units (OTUs [= neighbors]) that minimize the total branch length at each stage of clustering of OTUs starting with a starlike tree. The branch lengths as well as the topology of a parsimonious tree can quickly be obtained by using this method. Using computer simulation, we studied the efficiency of this method in obtaining the correct unrooted tree in comparison with that of five other tree-making methods: the unweighted pair group method of analysis, Farris's method, Sattath and Tversky's method, Li's method, and Tateno et al.'s modified Farris method. The new, neighbor-joining method and Sattath and Tversky's method are shown to be generally better than the other methods.
Objective: Angiotensin converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism influence the circulating and cellular levels of ACE and has been shown to be a risk factor in a number of diseases including IgA nephropathy. We have investigated the association of ACE gene I/D polymorphism with the clinical presentation of idiopathic nephrotic syndrome (INS) in Kuwaiti children. Materials and methods: The genotypes for ACE gene I/D polymorphism were determined in 102 subjects (54 INS cases and 48 healthy controls) using a PCR method. Results: The distribution of DD, ID and II genotypes was 70%, 20% and 10% in INS cases compared with 52%, 46% and 2% in the controls. The mean age of onset of the disease was significantly lower in the INS cases with DD genotype (37 months) compared with cases with II genotype (65 months, p < 0.05). The clinical manifestation of the disease was considerably severe in cases with DD genotypes compared with cases having ID and II genotypes. The INS cases with DD genot...