A comprehensive review published in Burns & Trauma on 15 June 2026 has brought together evidence that neutrophil extracellular traps (NETs) are central players in ischemia-reperfusion injury (IRI), a paradoxical condition where restoring blood flow after a heart attack, stroke, or transplantation can cause additional damage. The review, conducted by researchers from Chongqing University Central Hospital, Chongqing University, University Hospital Essen, University of Duisburg-Essen, and Ludwig-Maximilians-University Munich, systematically examines how neutrophils and NETs contribute to IRI across the heart, brain, kidney, liver, lung, and transplanted organs.
IRI is a shared pathological process in myocardial infarction, ischemic stroke, acute kidney injury, lung injury, and graft dysfunction after transplantation. Although rapid reperfusion remains essential for tissue survival, sudden oxygen restoration can activate sterile inflammation, reactive oxygen species (ROS) production, endothelial dysfunction, and immunothrombosis. Neutrophils arrive early at injured sites and release inflammatory mediators, proteases, and NETs—web-like structures composed of decondensed DNA, histones, myeloperoxidase (MPO), neutrophil elastase (NE), and other granular proteins. While NETs help trap microbes during infection, excessive NET formation in sterile injury can damage endothelial cells, promote microthrombus formation, and sustain inflammatory feedback loops.
The review explains that reperfusion injury often begins at the vascular interface. Damaged tissues and activated endothelial cells release damage-associated molecular patterns (DAMPs), cytokines, and chemokines, recruiting neutrophils into vulnerable microvessels. Activated neutrophils can then release NETs, which intensify inflammation, block microvessels, damage endothelial barriers, and spread injury across organs. By framing IRI as an immune-driven process, the work points to new biomarkers and therapeutic strategies that may help protect organs when blood flow returns.
A key strength of the review is its cross-organ perspective. In the heart, NETs can worsen cardiomyocyte injury and post-reperfusion inflammation. In the brain, NET accumulation may obstruct cerebral microvessels, disrupt the blood-brain barrier, and contribute to the mismatch between successful vessel reopening and poor neurological recovery. In the kidney and liver, NETs interact with tubular cells, hepatocytes, Kupffer cells, and sinusoidal endothelial cells, amplifying inflammation and graft dysfunction. The review also discusses the 'NET-organ axis,' in which NET-driven inflammation and thrombosis extend damage beyond the original injury site and contribute to multiple organ dysfunction syndrome (MODS). Biomarkers such as cell-free DNA (cfDNA), citrullinated histone H3 (CitH3), and MPO-DNA complexes may help monitor disease severity and therapeutic response.
The authors emphasize that NETs are dynamic immune structures rather than simple inflammatory debris. Their effects depend on timing, tissue context, and the balance between host defense and tissue damage. The therapeutic goal should not be to eliminate neutrophil function entirely, but to identify when NET formation becomes excessive, where it causes the greatest harm, and how it can be safely controlled. This perspective could help move NET-targeted treatment from broad immune suppression toward more precise, stage-specific intervention.
These findings may inform future strategies for reducing reperfusion-related injury in cardiovascular disease, stroke, transplantation, and critical care. Potential approaches include limiting harmful neutrophil recruitment, blocking peptidyl arginine deiminase 4 (PAD4)-dependent NET formation, reducing ROS-driven activation, modulating complement-related pathways, and accelerating NET clearance with deoxyribonuclease I (DNase I)-based therapies. However, the review emphasizes that clinical translation will require organ-specific biomarkers, careful timing, and strong safety evaluation, because NETs also support antimicrobial defense. With better patient stratification, NET-targeted therapies may offer a practical route to protecting organs after reperfusion.
For more details, the full review is available at https://doi.org/10.1093/burnst/tkag022.
