Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2021-049083 on 27 August 2021. Downloaded from Translational deep phenotyping of deaths related to the COVID-19 pandemic: protocol for a prospective observational autopsy study Mikkel Jon Henningsen ,1 Apameh Khatam- Lashgari,1 Kristine Boisen Olsen,1 Christina Jacobsen,1 Christian Beltoft Brøchner ,2 Jytte Banner1 To cite: Henningsen MJ, ABSTRACT Strengths and limitations of this study Khatam- Lashgari A, Olsen KB, Introduction The COVID-19 pandemic is an international et al. Translational deep emergency with an extreme socioeconomic impact and a ► A standardised, prospective autopsy study on COVID- phenotyping of deaths high mortality and disease burden. The COVID-19 outbreak related to the COVID-19 19- related deaths with systematic data collection. is neither fully understood nor fully pictured. Autopsy studies pandemic: protocol for a ► A multidisciplinary, translational approach elucidat- can help understand the pathogenesis of COVID-19 and has prospective observational ing changes from protein level to whole human. already resulted in better treatment of patients. Structured autopsy study. BMJ Open ► A comprehensive biobank and extensive registry and systematic autopsy of COVID-19- related deaths will 2021;11:e049083. doi:10.1136/ data as an umbrella for planned and future research. bmjopen-2021-049083 enhance the mapping of pathophysiological pathways, not ► The internal control group partly compensates for possible in the living. Furthermore, it provides an opportunity Prepublication history and the observational design. ► to envision factors translationally for the purpose of disease additional supplemental material ► Limited by a selected sample of COVID-19 diseased prevention in this and future pandemics. This is the protocol for this paper are available only including the ones undergoing autopsy. online. To view these files, for an autopsy study that offers an umbrella for deep and please visit the journal online. diverse investigations of COVID-19- related deaths, including (http:// dx. doi. org/ 10. 1136/ a systematic investigation of ‘long’ COVID-19 by means of bmjopen- 2021- 049083). extensive and systematic tissue sampling. and later evolved into the global COVID-19 Methods and analysis A COVID-19- specific autopsy pandemic that has claimed millions of lives. Received 20 January 2021 algorithm has been created to cover all cases undergoing Along with SARS- CoV2 and Middle East respi- Accepted 28 July 2021 clinical or forensic autopsy in Denmark. The algorithm ratory syndrome coronavirus (MERS- CoV),3 http://bmjopen.bmj.com/ describes advanced tissue sampling and a translational it is the third coronavirus that causes severe analytical follow-up for deep phenotyping. The translational symptoms in humans. Coronaviruses mutate approach covers registry data, postmortem imaging, gross frequently, and many variants of SARS- CoV-2, autopsy findings, microscopic organ changes, postmortem each with its own characteristics, have already toxicology, postmortem biochemical investigation, been registered.4 5 microbiological profiling and immunological status at Historically, autopsy studies have provided the time of death, and future research projects covering 6 genetics and epigenetics on an organ level. novel insights on epidemic disease. Important on September 30, 2021 by guest. Protected copyright. Ethics and dissemination This study has been approved knowledge of the pathophysiology of corona- by the Regional Ethics Committee of the Region of Greater virus was gained both from autopsy studies © Author(s) (or their Copenhagen (No: H-20078436) and the Danish Data during the SARS7 and MERS epidemics8 and employer(s)) 2021. Re- use Protection Agency (No: 2002-54-1080). Next of kin gave currently from autopsy studies on COVID-19- permitted under CC BY-NC. No informed consent to research. The study results will be related deaths.9–12 The importance of autopsy commercial re- use. See rights published in peer- reviewed journals. and permissions. Published by studies in the current pandemic is already BMJ. Trial registration number This study is purely observational reflected in better treatment of patients, for and, as such, does not meet the criteria of the International 1Section of Forensic example, adjusting anticoagulative therapy Committee of Medical Journal Editors for clinical trials; thus, Pathology, Department of for COVID-19.10 Besides a few cases in some there is no need for registration in a database of research trials, Forensic Medicine, University autopsy studies on COVID-19,13–16 only two of Copenhagen Faculty of such as clinical trials. To facilitate cooperation in research, 17 18 provide transparency on case recruitment for publications case series and a study by Romanova et Health and Medical Sciences, 19 Copenhagen, Denmark to come and to avoid unnecessary duplicate work, we al include out- of- hospital deaths. Autopsies 2Department of Pathology, nevertheless wish to publish our protocol. of hospital deaths demonstrate hospitalised Rigshospitalet, Copenhagen, fatal cases and late disease stages influenced Denmark by treatment and forensic autopsies provide Correspondence to INTRODUCTION an overview of different stages of disease. Professor Jytte Banner; In late 2019 in Wuhan, China, an outbreak of Much is known about the pathophysiology jytte. banner@ sund. ku. dk pneumonia caused by SARS- CoV-2 emerged,1 of SARS- CoV-2 but unanswered questions still Henningsen MJ, et al. BMJ Open 2021;11:e049083. doi:10.1136/bmjopen-2021-049083 1 Open access BMJ Open: first published as 10.1136/bmjopen-2021-049083 on 27 August 2021. Downloaded from remain. SARS- CoV-2 binds via its spike protein to ACE2 and tissue sampling,44 53 or rely on biopsies only.38 63–77 receptors located on different cell types, including type Studies with complete autopsies of 3–100 deceased have II alveolar cells, respiratory epithelial cells,5 7 20 21 myocar- been performed,9–12 47–50 78–90 but also some of these were dial cells,22 cells in the oesophagus and ileum, cells in restricted to ‘in situ’ organ examination.9 50 the kidneys and bladder, and endothelial cells,23 which Internationally, SARS-CoV -2 is classified into Hazard may explain the extrapulmonic symptoms observed in Group 3 and due to fear of transmission from the patients suffering from COVID-19.24 The transmembrane deceased to autopsy personnel, several guidelines on protease serine 2 (TMPRSS2) is also suspected to play a COVID-19 autopsies were published in the early stages vital role. of the pandemic by, for example, Hanley et al and It is well known that old age, and comorbidities such Santurro et al.91 92 In Denmark, SARS- CoV-2 is classified as cardiovascular disease (CVD), diabetes, chronic into Hazard Group 2.91 In this respect, the handling of lung disease, chronic kidney disease, cancer and those who die of a possible SARS- CoV-2 infection with 1 25–33 obesity increase the disease burden, and severe or without COVID-19 is possible following the standard COVID-19 includes sepsis, acute respiratory distress procedures at Danish autopsy facilities, including post- syndrome (ARDS), acute cardiac and kidney injury, mortem imaging, and furthermore allows for a compre- arrhythmia, as well as secondary infection and, ultimately, hensive autopsy study.10 93 1 27 34 death. The importance of CVD as a risk factor for Postmortem imaging has emerged as a promising tool increased morbidity and mortality during COVID-19 has for performing non- invasive ‘autopsy’,94 and may be of 29 31 32 become progressively apparent, but the exact patho- value in biohazardous cases. Only a few autopsy studies genesis is not fully understood. In the 2003 Toronto SARS have included postmortem imaging.95 outbreak, SARS- CoV viral RNA was detected in 35% of the autopsied hearts, and in these patients, the infection 22 Rationale for study was associated with a more aggressive course of illness. Autopsy studies enable extensive and unique exam- Myocardial injury was evident from rising levels of cardiac ination and tissue sampling, which is not possible in troponin I in those who did not survive,34 and in the living patients. No autopsy studies with extensive tissue current pandemic, inflammation and microthrombi have sampling were initiated during neither the SARS-CoV been detected in the coronary arteries.35 ARDS is well nor the MERS- CoV epidemic,6 and only a few studies in known from the SARS and MERS epidemics,36 37 and the the current SARS- CoV-2 pandemic include more than ongoing COVID-19 pandemic. The involvement of other 25 deceased.10–12 48 51 77 81 To our knowledge, no autopsy organs and the severity of COVID-19 are still not fully study on ‘long’ COVID-19 has been performed. understood and secondary effects mediated by a modi- This paper describes the protocol for an ongoing fication of the immunological reaction are assumed to multicentre autopsy study of COVID-19-related deaths, http://bmjopen.bmj.com/ contribute to the severity of COVID-19.1 36 38–40 and presents some of the planned and future research An emerging problem is so- called ‘long’ COVID-19, projects. The COVID-19 autopsies constitute a framework or postacute COVID-19, which is defined as persisting of complete, systematic autopsy, with multimodal post- symptoms and/or long- term complications, including mortem imaging, extensive predefined tissue sampling, neurological symptoms with disturbed senses, more than 41 including biobanking at −80°C, and toxicological,