Small-vessel vasculitis (SVV) is a chronic autoinflammatory condition linked to antineutrophil cytoplasm autoantibodies (ANCAs). Here we show that chromatin fibers, so-called neutrophil extracellular traps (NETs), are released by ANCA-stimulated neutrophils and contain the targeted autoantigens proteinase-3 (PR3) and myeloperoxidase (MPO). Deposition of NETs in inflamed kidneys and circulating MPO-DNA complexes suggest that NET formation triggers vasculitis and promotes the autoimmune response against neutrophil components in individuals with SVV.SVV is a relapsing-remitting autoinflammatory disorder leading to necrotic inflammation of small-sized blood vessels and capillaries 1 . ANCAs directed against granule proteins of neutrophils, namely against PR3 in Wegener's granulomatosis and MPO in microscopic polyangiitis, are implicated in the pathogenesis of SVV 2 . In vitro studies have demonstrated an activating effect of ANCAs on cytokine-primed neutrophils 3 , which was further corroborated by animal models of these diseases 4,5 . However, the basic mechanism that induces the life-threatening exacerbations of vasculitis and the sustained autoimmune response against neutrophil components remains elusive.A unique type of cell death of neutrophil granulocytes has recently been discovered that is characterized by the active release of chromatin fibers, so-called NETs, that trap and kill invading microbes extracellularly 6 . However, this glutinous DNA web can also stick to the endothelium and cause tissue damage during sepsis 7 , similar to neutrophil-induced As ANCA can activate the respiratory burst by binding to PR3 or MPO on the neutrophil surface 3 , we examined whether ANCA-mediated activation of neutrophils induces NET formation. We primed isolated neutrophils with tumor necrosis factor-α and incubated them with purified IgG from individuals with SVV or healthy donors as performed previously 3 . We observed robust NET formation (as determined by immunofluorescence 6,8; Supplementary Methods online) in neutrophils incubated with ANCA-IgG (Fig. 1a and Supplementary Table 1 online) but not in those incubated with control IgG, in which most nuclei retained the typical lobulated structure (Fig. 1b). After 180 min, we found that 23% of neutrophils incubated with ANCA-IgG produced NETs, compared to 11% of control IgG-treated neutrophils (Fig. 1c). Incubation with phorbol 12-myristate 13-acetate (PMA), known as a strong inducer of NETs, triggered NET production in 38% of all neutrophils (Fig. 1c). We also induced NETs with a PR3-specific mouse monoclonal antibody ( Supplementary Fig. 1 online), supporting the hypothesis that PR3-specific autoantibodies within the ANCA-IgG fraction trigger NET formation. ANCA-induced cell death of neutrophils was previously regarded as a dysregulated form of apoptosis 9 , but the link to NETs had not been noticed. The morphological changes of neutrophil nuclei clearly indicated to us that ANCA-induced NETs were of nuclear rather than of mitochondrial origin, as recently desc...

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ANCA testing is useful due to its high sensitivity and specificity, especially for cANCA/PR3-ANCA in WG. We found a divergence in the disease spectrum between PR3- and MPO-ANCA-positive patients, characterized by higher DEI and extrarenal manifestations in the PR3-ANCA group. MPO-ANCA was rarely found in WG and was associated with less organ involvement.

Steroid-resistant focal segmental glomerulosclerosis (FSGS) often recurs after renal transplantation. In this international survey, we sought to identify genotype-phenotype correlations of recurrent FSGS. We surveyed 83 patients with childhood-onset primary FSGS who received at least one renal allograft and analyzed 53 of these patients for NPHS2 mutations. The mean age at diagnosis was 6.7 years, and the mean age at first renal transplantation was 13 years. FSGS recurred in 30 patients (36%) after a median of 13 days (range, 1.5 to 152 days). Twenty-three patients received a second kidney transplant, and FSGS recurred in 11 (48%) after a median of 16 days (range, 2.7 to 66 days). None of the 11 patients with homozygous or compound heterozygous NPHS2 mutations developed recurrent FSGS compared with 45% of patients without mutations. These data suggest that genetic testing for pathogenic mutations may be important for prognosis and treatment of FSGS both before and after transplantation.