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The role of complement in long COVID pathogenesis
Rafael Bayarri-Olmos, … , William Bain, Akiko Iwasaki
Rafael Bayarri-Olmos, … , William Bain, Akiko Iwasaki
Published August 22, 2025
Citation Information: JCI Insight. 2025;10(16):e194314. https://doi.org/10.1172/jci.insight.194314.
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Review

The role of complement in long COVID pathogenesis

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Abstract

Long COVID is a debilitating condition that can develop after a SARS-CoV-2 infection and is characterized by a wide range of chronic symptoms, including weakness, neurocognitive impairment, malaise, fatigue, and many others, that affect multiple organ systems. At least 10% of individuals with a previous infection may develop long COVID, which affects their ability to perform daily functions and work. Despite its severity and widespread impact, this multisystemic condition remains poorly understood. Recent studies suggest that dysregulation of the complement system, a key component of the innate immune response, may contribute to the pathogenesis of long COVID, particularly in connection with coagulation, inflammation, and vascular injury. In this Review, we examine the evidence linking complement system dysregulation to long COVID and explore its potential role in driving disease pathology.

Authors

Rafael Bayarri-Olmos, William Bain, Akiko Iwasaki

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Figure 1

Overview of the complement system.

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Overview of the complement system.
The complement cascade can be initiat...
The complement cascade can be initiated by three distinct pathways: the classical, lectin, and alternative pathways. The classical and lectin pathways are triggered when recognition molecules bind to structures such as antibody complexes and carbohydrates on pathogen surfaces, leading to the activation of their associated proteases C1s/C1r and MASP-1/2. These proteases cleave C4 and C2, generating the C3 convertase (C4b2b), which then processes C3 into the anaphylatoxin C3a and the opsonin C3b. Accumulation of C3b induces the formation of the C5 convertase, which cleaves C5 into C5a and C5b. The subsequent interaction of C5b with C6, C7, C8, and C9 leads to the assembly of a lytic pore, known as the terminal complement complex (TCC). The alternative pathway is initiated when factor B (FB) interacts either with water-hydrolyzed C3, C3(H2O), or with deposited C3b to form the C3(H2O)Bb or C3bBb C3 convertases following factor D (FD) cleavage. These proteases, and in particular, the surface-bound and properdin/factor P–stabilized (FP-stabilized) C3bBbP C3 convertase act as an amplification loop for complement, generating most of the activated C3 fragments regardless of the initiating pathway.

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