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Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review)

  • Authors:
    • Jiandong Hu
    • Mengli Jin
    • Zhihua Cao
    • Binbin Zheng
    • Yuan Zheng
    • Hao Shen
  • View Affiliations / Copyright

    Affiliations: Core Laboratory, Tianjin Beichen Hospital, Tianjin 300400, P.R. China, Core Laboratory, Department of Critical Care Medicine, Tianjin Beichen Hospital, Tianjin 300400, P.R. China, Department of Cardiology, Tianjin Beichen Hospital, Tianjin 300400, P.R. China, Department of Respiratory Medicine, Tianjin Beichen Hospital, Tianjin 300400, P.R. China
    Copyright: © Hu et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
  • Article Number: 187
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    Published online on: May 4, 2026
       https://doi.org/10.3892/mmr.2026.13897
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Abstract

Sepsis affects an estimated 166 million individuals globally with 21.4 million annual deaths and represents a notable public health challenge. Sepsis‑induced coagulopathy (SIC) is a marked complication of sepsis, characterized by dysregulated hemostasis and microvascular thrombosis. Neutrophil extracellular traps (NETs) are pivotal mediators linking innate immunity to thrombo‑inflammation in this process. The present review systematically examined the epidemiology and pathogenesis of SIC, the molecular mechanisms of NET release (suicidal, vital, mitochondrial and non‑canonical pathways) and the mechanistic pathways by which NETs regulate SIC. NETs disrupt endothelial integrity, amplify platelet activation, propagate coagulation cascades and suppress fibrinolysis, thereby establishing a self‑amplifying cycle that accelerates progression to disseminated intravascular coagulation and multiple organ failure. Furthermore, the present review highlighted current therapeutic strategies targeting NETs, including inhibition of NET synthesis, acceleration of NET clearance and disruption of platelet‑neutrophil interactions. Elucidating the central role of NETs in SIC pathophysiology may facilitate the development of novel biomarkers and precision therapeutic interventions for this life‑threatening condition.
View Figures

Figure 1

Mechanistic pathways of SIC
pathogenesis. The pathogenesis of SIC involves six interconnected
regulatory mechanisms. i) TF activation: Pathogen LPS binds to TLR4
on VECs, triggering MyD88/TRIF-dependent signaling and subsequent
NF-0B/IRF3 pathway activation, leading to rapid TF expression and
initiation of the extrinsic coagulation cascade. ii)
Platelet-endothelial-glycocalyx axis: Inflammatory injury causes
degradation of the endothelial glycocalyx layer, exposing
subendothelial collagen and vWF. Activated platelets adhere via
GPIb-IX–V receptors and release ADP, TXA2 and PF4,
promoting primary thrombus formation. iii) Natural anticoagulant
consumption: Proinflammatory cytokines suppress hepatic synthesis
of antithrombin and protein C, while NE degrades TFPI, resulting in
diminished anticoagulant capacity. iv)
Inflammation-complement-crosstalk: Complement activation generates
C3a and C5a anaphylatoxins that activate platelets and recruit
leukocytes, whereas MAC formation exposes procoagulant
phospholipids, establishing a positive feedback loop among
inflammation, complement and coagulation systems. v)
Mitochondria-ROS-Ca2+ axis: Mitochondrial dysfunction
induced by ROS causes ATP depletion and disruption of
Na+/Ca2+ homeostasis, resulting in
cytoplasmic Ca2+ overload that enhances
Ca2+-dependent coagulation enzyme complex assembly. vi)
NETs structure and function: The ROS-PAD4 signaling pathway drives
histone citrullination and NET release, providing DNA backbone
decorated with NE, MPO and cathepsin G that facilitate thrombus
propagation. SIC, sepsis-induced coagulopathy; NE, neutrophil
elastase; MPO, myeloperoxidase; PAD4, peptidylarginine deiminase 4;
ROS, reactive oxygen species; TF, tissue factor; TFPI, TF pathway
inhibitor; vWF, von Willebrand factor; VECs, vascular endothelial
cells; LPS, lipopolysaccharide; TLR-4; TXA2, thromboxane
A2; PF4, platelet factor 4; MAC, membrane attack
complex; NET, neutrophil extracellular trap.

Figure 2

Molecular pathways of NET release.
(A) Suicidal NETosis: Receptor activation elevates intracellular
Ca2+, stimulating PKC and NOX assembly to generate ROS.
ROS-activated MPO promotes chromatin decondensation and nuclear
envelope rupture, while NE translocates to the nucleus. Decondensed
chromatin is expelled through GSDMD pores, resulting in neutrophil
death. (B) Vital NETosis: TLR signaling activates PAD4 in a
NOX-independent manner, inducing histone citrullination and nuclear
envelope dissolution. DNA-protein complexes are packaged into
vesicles and released extracellularly within 30 min-2 h.
Neutrophils remain viable as anucleate cytoplasts with preserved
chemotactic and phagocytic functions. (C) Mitochondrial NETs:
GM-CSF/LPS/C5a stimulation activates SK3 channels, causing
ROS-dependent mitochondrial swelling and mtDNA release.
mtDNA-granule complexes are expelled via vesicles or autophagy
within <20 min without compromising neutrophil viability. (D)
Non-canonical NETosis: Intracellular Gram-negative bacteria trigger
non-canonical inflammasome activation, with caspase-4/11 driving
pyroptosis-dependent DNA extrusion through GSDMD. This pathway
proceeds independent of NE and MPO. GSDMD, gasdermin D; MPO,
myeloperoxidase; mtDNA, mitochondrial DNA; NE, neutrophil elastase;
NOX, NADPH oxidase; PAD4, peptidylarginine deiminase 4; PKC,
protein kinase C; ROS, reactive oxygen species; SK3, small
conductance calcium-activated potassium channel 3; TLR, Toll-like
receptor; NET, neutrophil extracellular trap; LPS,
lipopolysaccharide; GM-CSF, granulocyte-macrophage colony
stimulating factor.

Figure 3

Mechanisms of NET regulation in SIC.
Central panel: Schematic overview of SIC microthrombosis,
illustrating NET release from neutrophils within the vascular
lumen, formation of NET scaffolds (DNA and histones), and
subsequent microthrombus formation on VECs. (A) Endothelial injury:
NETs disrupt the endothelial glycocalyx barrier and induce
endothelial ferroptosis, leading to barrier collapse. Mac-1/ICAM-1
interactions between neutrophils and VECs facilitate neutrophil
adhesion and NETosis. NET-derived DNA activates the cGAS-STING
pathway in VECs, while pro-inflammatory cytokines IL-6 and TNF-α
and TF upregulation promote a procoagulant endothelial phenotype.
(B) NET-platelet interactions: P-selectin/PSGL-1 binding initiates
bidirectional activation between platelets and neutrophils. The
PF4-heparin-IgG complex activates neutrophils via FcγRIIA,
triggering NOX2-mediated NETosis and establishing an
inflammation-thrombosis cycle. NETs reciprocally entrap platelets,
amplifying thrombotic responses. (C) Impaired regulation:
NET-associated NE degrades AT and TFPI, while PAD4-mediated
citrullination inactivates TFPI. NETs impair protein C activation
and confer resistance to tPA, resulting in dense fibrin-DNA clots
with altered fibrin structure that resist fibrinolysis. (D)
Coagulation activation: NETs activate the intrinsic coagulation
pathway through FXII activation, leading to downstream activation
of FXI and thrombin generation. Histone-induced TF expression on
VECs initiates the extrinsic pathway. NETs provide scaffolds for
vWF bridging and fibrin deposition, promoting clot formation. SIC,
sepsis-induced coagulopathy; AT, antithrombin; cGAS-STING, cyclic
GMP-AMP synthase-stimulator of interferon genes; FcγRIIA, Fc gamma
receptor IIA; FXII, coagulation factor XII; ICAM-1, intercellular
adhesion molecule-1; IL-6, interleukin-6; Mac-1, macrophage-1
antigen; NET, neutrophil extracellular trap; NOX2, NADPH oxidase 2;
PAD4, peptidylarginine deiminase 4; PF4, platelet factor 4; PSGL-1,
P-selectin glycoprotein ligand-1; TF, tissue factor; TFPI, tissue
factor pathway inhibitor; tPA, tissue plasminogen activator; TNF-α,
tumor necrosis factor-alpha; VECs, vascular endothelial cells; vWF,
von Willebrand factor; NE, neutrophil elastase.

Figure 4

Therapeutic strategies targeting NETs
in sepsis-induced coagulopathy. The diagram illustrates three major
therapeutic approaches: 1) Inhibition of NET synthesis: Multiple
targets block NET formation at different stages, NOX2 blockade
reduces ROS generation; RTM attenuates cytokine storm via TLR4
signaling inhibition; αAAT inhibits NE activity; PAD4 inhibition or
gene silencing prevents histone citrullination; and disulfiram
blocks GSDMD pore formation to prevent NET extrusion. 2)
Acceleration of NET clearance and nucleosome inhibition: DNase
treatment accelerates NET degradation; anti-histone antibodies
neutralize cytotoxicity of free histones; hPF4 stabilizes NETs and
prevents ssDNA generation; and cfDNA clearance reduces circulating
nucleosome levels. 3) Blockade of platelet-neutrophil interactions:
P2Y₁2 antagonists (ticagrelor/clopidogrel) downregulate
P-selectin expression; paquinimod blocks platelet TLR4 signaling;
and combined ticagrelor-sivelestat therapy inhibits platelet
pyroptosis and platelet-neutrophil aggregate formation via PSGL-1
inhibition. AAT, α-1 antitrypsin; cfDNA, cell-free DNA; DNase,
deoxyribonuclease; GSDMD, gasdermin D; hPF4, human platelet factor
4; NE, neutrophil elastase; NET, neutrophil extracellular trap;
NOX2, NADPH oxidase 2; PAD4, peptidylarginine deiminase 4; PSGL-1,
P-selectin glycoprotein ligand-1; ROS, reactive oxygen species;
RTM, recombinant thrombomodulin; ssDNA, single-stranded DNA; TLR4,
Toll-like receptor 4; NE, neutrophil elastase.
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Copy and paste a formatted citation
Spandidos Publications style
Hu J, Jin M, Cao Z, Zheng B, Zheng Y and Shen H: Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review). Mol Med Rep 34: 187, 2026.
APA
Hu, J., Jin, M., Cao, Z., Zheng, B., Zheng, Y., & Shen, H. (2026). Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review). Molecular Medicine Reports, 34, 187. https://doi.org/10.3892/mmr.2026.13897
MLA
Hu, J., Jin, M., Cao, Z., Zheng, B., Zheng, Y., Shen, H."Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review)". Molecular Medicine Reports 34.1 (2026): 187.
Chicago
Hu, J., Jin, M., Cao, Z., Zheng, B., Zheng, Y., Shen, H."Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review)". Molecular Medicine Reports 34, no. 1 (2026): 187. https://doi.org/10.3892/mmr.2026.13897
Copy and paste a formatted citation
x
Spandidos Publications style
Hu J, Jin M, Cao Z, Zheng B, Zheng Y and Shen H: Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review). Mol Med Rep 34: 187, 2026.
APA
Hu, J., Jin, M., Cao, Z., Zheng, B., Zheng, Y., & Shen, H. (2026). Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review). Molecular Medicine Reports, 34, 187. https://doi.org/10.3892/mmr.2026.13897
MLA
Hu, J., Jin, M., Cao, Z., Zheng, B., Zheng, Y., Shen, H."Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review)". Molecular Medicine Reports 34.1 (2026): 187.
Chicago
Hu, J., Jin, M., Cao, Z., Zheng, B., Zheng, Y., Shen, H."Research progress on neutrophil extracellular traps in sepsis‑induced coagulopathy (Review)". Molecular Medicine Reports 34, no. 1 (2026): 187. https://doi.org/10.3892/mmr.2026.13897
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