The ligand-binding capacity of Na-FAR-1 was investigated with the fluorescent ligands 11-(dansylamino)undecanoic acid (DAUDA) and retinol. Stock solutions (10 mM) were prepared in ethanol and then diluted in PBS for use in the assays. Retinol solutions were diluted in ethanol and added directly to the cuvette to minimize degradation.

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The 3D structure of Na-FAR-1 was determined by both protein X-ray crystallography and solution state NMR spectroscopy. Na-FAR-1, which had not been subjected to reverse phase HPLC purification to strip out co-purifying ligands, crystallized as previously reported and diffracted to 2/14 Å .


The differences in the size and shape of the internal cavities of Ce-FAR-7 and Na-FAR-1 are probably indicative of differences in their ligand selectivity. Both proteins bind retinol and FAs, but whether these compounds are relevant in vivo and whether other classes of ligand (such as PLs here found to be bound by Na-FAR-1) are important, remains to be established. The fact that FARs are commonly found in the secretions of parasitic nematodes bolsters confidence that they play an important role in parasitism. Parasites need to acquire nutrients from their hosts, but also need to defend themselves against immune defence reactions and some parasites induce modifications to the tissues they occupy. If FARs do bind signalling lipids, then it is conceivable that they are released by parasites in order to subvert or modify the hosts’ tissue and defence reactions. If so, then FARs would seem to be logical targets for vaccines, particularly against parasites that are embedded in host tissues. Development of drugs against them would need to take into account the possibility of interference with the hosts’ proteins and enzymes that transport or modify FAs and retinoids. But, it is entirely possible that we have yet to discover the true range of the ligand-binding propensities of FARs in nematodes. An understanding of their structures and how they vary between those secreted by different species of parasites could illuminate their roles in parasitism and suggest possible targets for therapeutic interventions.

Taken together, these findings suggest that the urine ACE2 as not an ideal parameter for assessing the therapeutic effect of RAS blockade therapy in diabetic nephropathy. The effects of RAS blockers on expression of urinary ACE2 need to be further investigated.


The urinary ACE2 assay could be affected by different factors some of which are still lying unidentified. Therefore, there is a need to establish the reliability of these methods and identify conditions that best suit their applications. At present, there is no published information regarding their comparability, advantages and limitations. Their performances ought to be evaluated not only for future adaption in the clinical practice but also research in which they are already being used.

Since its identification in early 2000’s, the value of urinary ACE2 in the management of diabetic nephropathy has never been appreciated. We explored recent studies and examined relationships between urinary ACE2 and clinical parameters to highlight possible applications in management of diabetic nephropathy. This review summarizes what has already achieved and sets a stage for new studies.


Urinary ACE2 was significantly associated with metabolites including blood glucose, cholesterol and triglycerides. The association with glucose was noteworthy as blood glucose alone influenced the renal expression of ADAM 17, a protein responsible for urinary shedding of ACE2. The enzyme activity and protein expression of ACE2 were both attenuated by administration of insulin, rosiglitazone and metformin, agents known to correct hyperglycaemia. Collectively, the studies suggested urinary ACE2 as an indicator glucose metabolic status among the diabetics.

Characterization of angiotensin-converting enzyme 2 ectodomain shedding from mouse proximal tubular cells

Fatty acid (try these out) and retinol-binding proteins (FARs) comprise a family of unusual α-helix rich lipid-binding proteins found exclusively in nematodes. They are secreted into host tissues by parasites of plants, animals and humans. The structure of a FAR protein from the free-living nematode Caenorhabditis elegans is available, but this protein [C. elegans FAR-7 (Ce-FAR-7)] is from a subfamily of FARs that does not appear to be important at the host/parasite interface. We have therefore examined [Necator americanus FAR-1 (Na-FAR-1)] from the blood-feeding intestinal parasite of humans, N. americanus. The 3D structure of Na-FAR-1 in its ligand-free and ligand-bound forms, determined by NMR (nuclear magnetic resonance) spectroscopy and X-ray crystallography respectively, reveals an α-helical fold similar to Ce-FAR-7, but Na-FAR-1 possesses a larger and more complex internal ligand-binding cavity and an additional C-terminal α-helix. Titration of apo-Na-FAR-1 with oleic acid, analysed by NMR chemical shift perturbation, reveals that at least four distinct protein–ligand complexes can be formed. Na-FAR-1 and possibly other FARs may have a wider repertoire for hydrophobic ligand binding, as confirmed in the present study by our finding that a range of neutral and polar lipids co-purify with the bacterially expressed recombinant protein. Finally, we show by immunohistochemistry that Na-FAR-1 is present in adult worms with a tissue distribution indicative of possible roles in nutrient acquisition by the parasite and in reproduction in the male.


Distance restraints were derived from NOESY (nuclear Overhauser effect spectroscopy) cross-peaks with the initial mapping from normalized intensity to distance and grouped in distance bins. NOE distance restraints were incorporated in restrained MD calculations using the ambiguous distance restraints formalism using ARIA 2/3 and CNS . Loose backbone dihedral restraints for regions of regular secondary structure predicted based on secondary chemical shifts by DANGLE were incorporated during the high temperature phases of the simulations but omitted during the final cooling phase. RDC and hydrogen bond restraints were then introduced. The average RDC alignment tensor was estimated from the ensemble calculated using only NOEs with PALES and used to incorporate the RDC restraints via the SANI potential in square-well mode. The 20 structures that best satisfy the experimental restraints were chosen from 100 structures generated in the final iteration and refined in explicit water . The quality of these structures was analysed using PROCHECK_nmr and their co-ordinates deposited in the Protein Data Bank under accession code 4UET.

It also became apparent in this review that the increase in urinary ACE2 is not specific to diabetes or diabetic nephropathy. Urinary ACE2 was also significantly increased in the non-diabetic kidney diseases although highly augmented in diabetes (19, 22). The non-diabetic kidney diseases have of recent posed a challenge to the management of diabetic nephropathy as they have been reported to occur with diabetic nephropathy. The most important non diabetic kidney diseases known to complicate diabetic nephropathy include immunoglobulin A nephropathy and membranous nephropathy (35). The renal pattern of ACE2 in immunoglobulin A nephropathy was by coincidence found identical to that of diabetic nephropathy suggesting that ACE2 influences the progression of diabetic and non-diabetic kidney diseases in a similar manner (36). This notwithstanding, the expression of urine ACE2 in immunoglobulin A and membranous nephropathies has never been studied. Accordingly, future studies should also examine and elucidate the potential that urinary ACE2 may hold for the diabetic nephropathy-complicating non diabetic renal diseases.

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The sample used for residual dipolar coupling (RDC) measurements was prepared by partial alignment of the uniformly 13C15N-enriched Na-FAR-1 in a solution of magnetically aligned filamentous Pf1 bacteriophage (ASLA biotech). The degree of alignment was evaluated by measuring the 2H quadrapolar splitting in the HDO resonance. After testing several conditions, a NaCl concentration of 300 mM with 9 mg·ml−1 of bacteriophage and 300 μM protein was selected.

It is therefore plausible to speculate that RAS blockers possess functional differences which, perhaps, are responsible for the varied effects on urinary ACE2. Moreover some functional differences were reported with the use of ARBs (46).


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Urinary ACE2 was found associated with metabolites such as triglycerides, total cholesterol and glucose in diabetic patients (16, 20). Metabolic abnormalities of these metabolites are associated with increased risk of CKD (40). Of all metabolites, glucose was the most studied in relation to urinary expression of ACE2. There is an increasing body of evidence implicating glucose in the urinary shedding of ACE2. Urinary ACE2 was significantly attenuated by insulin, rosiglitazone and metformin with/without exercise, the agents known to correct high blood glucose concentrations (23-26). Urine ACE2 was significantly correlated with glycated haemoglobin, a product of elevated blood glucose (16). The association of urine ACE2 with blood glucose was noteworthy as it is only glucose that has so far been shown to influence the renal expression of ADAM17, a protease responsible for the shedding of ACE2 (24, 27). It is therefore evident that urinary ACE2 is dependent on blood glucose, a metabolite whose deranged metabolism underlies diabetic nephropathy.

The expression of urinary angiotensin converting enzyme 2 in diabetic subjects with and without nephropathy

Albumin, nephrin and L-FABP are renal parameters of whose presence in urine is indicative of renal dysfunction. Urine albumin is currently used in diagnosis and prognosis diabetic nephropathy while urinary nephrin and L-FABP are indicators of glomerular and tubulointerstial injury that occurs in the early stages of kidney disease. Like urinary ACE2, both nephrin and L-FABP were significantly increased among normoalbuminuric patients, positively correlated with proximal tubular dysfunction and negatively associated with eGFR (14, 37, 38). These observations suggest that urinary ACE2 rises in early stages of diabetes and could reflect the state of kidney function, an attribute of a good diagnostic and prognostic biomarker. The prognostic potential of urinary ACE2 was further underpinned by a recent study in which urinary ACE2 was listed among biomarkers that could predict the progression of diabetic renal disease in the early stages (39).


It was observed in most of the studies that ACEIs and ARBs did not alter the activity, protein and mRNA levels of urine ACE2. Although this was the case in almost all studies, a few reported otherwise (22, 26, 29, 32). For instance the use of Olmesartan, an ARB was reported to increase the urine expression of ACE2 while the use of RAS inhibitors attenuated the augmented expression of ACE2 among the hypertensive diabetics (16, 30). Although the decrease in expression of ACE2 caused by RAS inhibitors in the Liang et al. study was significant enough to serve a measure therapeutic effect, it only occurred among the hypertensive diabetics (16). This observation conflicted with the Abe et al. study in which Olmesartan increase the urine expression of ACE2 (30).

Relaxation times T1 and T2 were calculated using non-linear least squares fitting. Collection of 15N-HSQC-heteronuclear NOE experiments with and without saturation allowed extraction of 1H,15N NOE values. Both saturation and reference experiments were repeated for the purpose of error estimation.

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Relationship between renal injury and the antagonistic roles of angiotensin-converting enzyme and ACE2

It was evident however, on the basis of the reviewed studies, that the assay of protein and enzyme activity gives comparable results (Table 1). As such, both can be relied upon as indices of urinary ACE2 considering their concurrent increased expression among diabetic patients. It is thus irrational to measure both activity and protein per current practice. The assay of either protein or enzyme activity would suffice saving time and other resources.


The protein expression and enzyme activity were significantly increased among diabetic patients (18-20, 22). The diabetic renal transplant recipients also excreted higher amounts of urine ACE2 protein compared to their non-diabetic counterparts (21). In study form Xiao et al. all three expression forms were studied but unlike the mRNA which remained unchanged, the enzyme activity and protein expressions were significantly increased (21).

We also reviewed recent studies for associations of urinary ACE2 with serum creatinine and eGFR, the parameters used in staging of CKD. Urinary ACE2 was associated with serum creatinine and advanced stages of diabetic nephropathy in spite of the insignificant correlation with eGFR (18, 20, 24, 30). The concentration of ACE2 was found significantly higher in diabetic patients at CKD stage 4 (defined as eGFR = 30 mL/min/1/73m2), suggesting a possible role in the staging of chronic diabetic kidney disease (19). Currently, the staging of CKD is done in accordance with KDIGO 2021 clinical practice guideline for the evaluation and management of chronic kidney disease. It makes use of eGFR calculated with the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation whose performance was found better than other equations including the Modification of Diet in Renal Disease (MDRD) (41-43).


The presence of ACE2 in urine is determined by the urine assays for three expression forms namely; ACE2 protein, ACE2 mRNA and the enzymatic activity. Angiotensin converting enzyme 2 protein is quantitatively determined by enzyme linked immunosorbent assay (ELISA) and immunoblotting while the enzyme activity and mRNA are quantified by fluorometry and real time polymerize chain reaction (RT-PCR), respectively (16, 18-26, 29-32).

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The quantification of urinary ACE2 requires freshly collected or preserved urine samples. Pending analysis, collected urine samples can be kept at - 80 oC for a period less than 2 months to avoid deterioration. The measurement of ACE2 by ELISA, immunoblotting and fluorometry requires urine supernatant while RT-PCR requires urine pellets. ELISA kits, polyacrylamide gel and ACE2-specific substrates required for ACE2 ELISA, immunoblotting and fluorometry are all commercially available. The commonly used ACE2 – specific synthetic substrates are o-amino-benzoic acid-Ser-Pro-Tyr(NO2)-OH and Mca-APK(Dnp) (16, 18, 21, 23-26, 31). Laboratory procedures for ACE2 ELISA, immunoblotting, fluorometry and RT PCR were detailed by Xiao et al. (21).

Due to the consistence in expression of ACE2 protein and enzyme activity as observed in majority of the studies, it is tempting to conclude that the two are more reliable than the measurement of ACE2 mRNA. The reliability of these expressional forms of ACE2 need to be evaluated in well-designed studies with representative samples sizes as the reviewed studies on ACE2 mRNA were too few for such a conclusion.


Presently, there are no reliable means of identifying diabetic patients at risk of developing diabetic nephropathy. Although albuminuria is currently being used for this purpose, it serves no value among the 50% diabetic patients who remain normalbuminuric but develop renal insufficiency (10). Accordingly, new biomarkers with better performance are needed. We reviewed and analysed the plausibility of having urinary ACE2 as a diagnostic and prognostic biomarker of diabetic nephropathy. We assessed its potential by how it relates with the established metabolic and renal parameters among the diabetic patients with and without nephropathy.

ACEI - angiotensin converting enzyme inhibitor. ARB - angiotensin receptor blocker.


Although ELISA, real time RT-PCR and fluorometry have for long been used to measure urinary ACE2 mainly for research purposes, their performances are not yet evaluated. A few inconsistencies regarding the use of these assay techniques have been encountered but not formally reported. Measured by ELISA, the level of urine ACE2 was found significantly decreased upon induction of hyperglycaemia among the previous euglycaemic patients (31). This observation suggested ELISA as insensitive to ACE2 in hyperglycaemia, it still waits to be resolved. Furthermore, the level of ACE2 protein was found increased in diabetic transplant recipients as the mRNA remained unchanged in the same subjects under similar conditions (21). In spite of the difference between ACE2 protein and ACE2 mRNA expression forms, this observation suggested that the two methods are incomparable.

The structure of one FAR protein, C. elegans FAR-7 (Ce-FAR-7), has been solved by X-ray crystallography, revealing a helix-rich structure that is unlike any type of lipid-binding protein previously described . The mRNA for Ce-FAR-7 does not encode a secretory signal peptide and its amino acid (https://dkluchezar.ru/hack/?patch=1566) sequence indicates that it is in a different subfamily of FARs from those that are secreted from the synthesizing cell. We set out to confirm the expression pattern of a secreted FAR protein from a parasite and characterize its structure and ligand-binding characteristics. The protein Na-FAR-1 derives from the blood feeding intestinal hookworm of humans, N. americanus. This parasite and the other hookworm of humans, Ancylostoma duodenale, together infect over 300 million people worldwide [25,26], causing considerable morbidity, together with adverse social and economic consequences. We have determined the structure of Na-FAR-1 by both X-ray crystallography and NMR spectroscopy in solution. We find that it has a similar overall fold to Ce-FAR-7, indicating that FARs are structurally conserved despite considerable sequence diversity. But, in addition to the structural differences between Ce-FAR-7 and Na-FAR-1, we find that their ligand-binding sites differ significantly in position and form.


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Angiotensin converting enzyme 2 was expressed in urine of diabetic and non-diabetic subjects at the level of protein and mRNA. Being an enzyme, ACE2 exhibited a catalytic activity the assay of which was also used to determine its urinary expression. The quantification of ACE2 protein and the assay of enzyme activity were the preferred methods of studying the expression of urine ACE2. In most studies, ACE2 protein and enzyme activity were concurrently measured. These studies yielded comparable results for the enzyme activity and protein expression but not ACE2 mRNA whose expression conformed to none of the two. The enzyme activity and protein expression were significantly increased in diabetes, unlike mRNA whose expression remained unchanged. The utility of ACE2 protein and enzyme activity was evident and supported by many studies while that of ACE2 mRNA was less evident and supported by few studies. The urine expression ACE2 mRNA should therefore be interpreted separately and cautiously as it may not represent the enzyme activity and protein expression of ACE2. In studying urinary of ACE2, the assay of either ACE2 protein or enzyme activity but not both is recommended since the two expressional forms associate well in diabetics.


All studies reported a positive association between urinary ACE2 and all/ majority of the renal and metabolic parameters except one (16, 18-21, 23-25, 29, 30, 32). The relationships ranged strong to weak perhaps depending on the severity diabetes and the degree of renal impairment.

Increased urinary angiotensin-converting enzyme 2 in renal transplant patients with diabetes

A survey of the recent studies indicated that urine ACE2 is significantly expressed in the diabetic subjects compared to the non-diabetic. The study findings regarding expression of ACE2 protein, enzyme activity and mRNA are as summarized in Table 1.