title: Release of neutrophil extracellular traps by neutrophils stimulated with antiphospholipid antibodies: a newly identified mechanism of thrombosis in the antiphospholipid syndrome.
abstract: OBJECTIVE
  Antiphospholipid antibodies (aPL), especially those targeting β2 -glycoprotein I (β2 GPI), are well known to activate endothelial cells, monocytes, and platelets, with prothrombotic implications. In contrast, the interaction of aPL with neutrophils has not been extensively studied. Neutrophil extracellular traps (NETs) have recently been recognized as an important activator of the coagulation cascade, as well as an integral component of arterial and venous thrombi. This study was undertaken to determine whether aPL activate neutrophils to release NETs, thereby predisposing to the arterial and venous thrombosis inherent in the antiphospholipid syndrome (APS).
  
  
  METHODS
  Neutrophils, sera, and plasma were prepared from patients with primary APS (n = 52) or from healthy volunteers and characterized. No patient had concomitant systemic lupus erythematosus.
  
  
  RESULTS
  Sera and plasma from patients with primary APS had elevated levels of both cell-free DNA and NETs, as compared to healthy volunteers. Freshly isolated neutrophils from patients with APS were predisposed to high levels of spontaneous NET release. Further, APS patient sera, as well as IgG purified from APS patients, stimulated NET release from control neutrophils. Human aPL monoclonal antibodies, especially those targeting β2 GPI, also enhanced NET release. The induction of APS NETs was abrogated with inhibitors of reactive oxygen species formation and Toll-like receptor 4 signaling. Highlighting the potential clinical relevance of these findings, APS NETs promoted thrombin generation.
  
  
  CONCLUSIONS
  Our findings indicate that NET release warrants further investigation as a novel therapeutic target in APS.
authors.affiliation: University of Michigan, Ann Arbor.
authors.forename: Srilakshmi
authors.initials: S
authors.lastname: Yalavarthi
authors.affiliation: McMaster University, Hamilton, Ontario, Canada.
authors.forename: Travis J
authors.initials: TJ
authors.lastname: Gould
authors.affiliation: University of Michigan, Ann Arbor.
authors.forename: Ashish N
authors.initials: AN
authors.lastname: Rao
authors.affiliation: University of Michigan, Ann Arbor.
authors.forename: Levi F
authors.initials: LF
authors.lastname: Mazza
authors.affiliation: University of Michigan, Ann Arbor.
authors.forename: Alexandra E
authors.initials: AE
authors.lastname: Morris
authors.affiliation: Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
authors.forename: Carlos
authors.initials: C
authors.lastname: Núñez-Álvarez
authors.affiliation: Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
authors.forename: Diego
authors.initials: D
authors.lastname: Hernández-Ramírez
authors.affiliation: University of Michigan, Ann Arbor.
authors.forename: Paula L
authors.initials: PL
authors.lastname: Bockenstedt
authors.affiliation: McMaster University, Hamilton, Ontario, Canada.
authors.forename: Patricia C
authors.initials: PC
authors.lastname: Liaw
authors.affiliation: Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
authors.forename: Antonio R
authors.initials: AR
authors.lastname: Cabral
authors.affiliation: University of Michigan, Ann Arbor.
authors.forename: Jason S
authors.initials: JS
authors.lastname: Knight
mesh_terms: D017152:Antibodies, Antiphospholipid / Q000276:immunology*; D016736:Antiphospholipid Syndrome / Q000276:immunology* / Q000378:metabolism; D065206:Extracellular Traps; D006801:Humans; D007074:Immunoglobulin G / Q000276:immunology; D009504:Neutrophils / Q000276:immunology* / Q000378:metabolism; D017382:Reactive Oxygen Species / Q000378:metabolism; D015398:Signal Transduction / Q000502:physiology; D013927:Thrombosis / Q000276:immunology* / Q000378:metabolism; D051197:Toll-Like Receptor 4 / Q000378:metabolism
chemical_list: D017152:Antibodies, Antiphospholipid; D007074:Immunoglobulin G; D017382:Reactive Oxygen Species; C495345:TLR4 protein, human; D051197:Toll-Like Receptor 4