Targeting specific immune pathways could prevent severe reperfusion injury

IRI is a shared pathological process in myocardial infarction, ischaemic 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 neutrophil extracellular traps (NETs). Yet NETs are not uniformly harmful; their effects may differ by organ, disease stage, and local microenvironment. Due to these problems, in-depth research is needed on the organ-specific mechanisms, timing, biomarkers, and therapeutic windows of NET-mediated IRI.

Researchers from Chongqing University Central Hospital (Chongqing Emergency Medical Center), Chongqing University, University Hospital Essen, University of Duisburg-Essen, and Ludwig-Maximilians-University Munich published (DOI: 10.1093/burnst/tkag022) the review in Burns & Trauma on 15 June 2026. The article systematically examines how neutrophils and NETs contribute to IRI across the heart, brain, kidney, liver, lung, and transplanted organs, while assessing their potential as biomarkers and therapeutic targets.

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 are 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.

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 myeloperoxidase-DNA (MPO-DNA) complexes may help monitor disease severity and therapeutic response.

The authors said the review highlights NETs as dynamic immune structures rather than simple inflammatory debris. Their effects depend on timing, tissue context, and the balance between host defense and tissue damage. They said 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.