PAD4-mediated histone citrullination contributes to enhanced NETosis in type 2 diabetes but not in type 1 diabetes

Neutrophil extracellular traps (NETs) are web-like structures released by activated neutrophils through a process known as NETosis, which help immobilize, trap, and eliminate invading pathogens. While NETs play a critical role in host defense, excessive or dysregulated NET formation can contribute to chronic inflammatory diseases such as diabetes and its complications. Elevated levels of NETs and increased expression of its mediator, protein-arginine deiminase type 4 (PAD4), have been reported in diabetes. However, the underlying molecular mechanisms governing the enhanced NETosis in type 1 (T1D) and type 2 diabetes (T2D) remain unclear. Using mouse models and human patient samples, we show that neutrophils undergo enhanced NETosis in T1D and T2D through distinct pathways. We found enhanced NETosis in T1D occurs in a PAD4-independent manner, driven by robust cytosolic ROS production by NADPH oxidase (NOX). This leads to myeloperoxidase activation and chromatin decondensation. We further confirm the PAD4 independent mechanism in neutrophils from STZ-induced PAD4-/- mice. In contrast, in T2D, neutrophils undergo NOX-independent NETosis, which relies on calcium-mediated mitochondrial ROS production, PAD4 activation, and hyper-histone citrullination. Taken together, our findings reveal previously uncharacterized distinct mechanisms of enhanced NETosis in T1D and T2D.