Glomerular Endothelial Rarefaction Associated With Hypoxic Neutrophils Marks Renal Pathology Activity in Lupus Nephritis

OBJECTIVE: This study aims to investigate the spatial transcriptomics of hypoxia and immune-mediated damage within renal tissue in patients with lupus nephritis (LN) in comparison to healthy controls from kidney transplants. METHODS: Renal biopsies from patients with LN and transplant controls were imaged using multiplexed cyclic immunofluorescence to spatially quantify immune and endothelial cell markers. An independent LN cohort of patients underwent Visium spatial transcriptomics analysis. Hypoxia was modeled in cell lines and primary neutrophils using cobalt chloride, and urinary neutrophil cargo proteins were measured using an enzyme-linked immunosorbent assay. RESULTS: neutrophils along with diffuse perinuclear staining for myeloperoxidase (MPO), indicative of heightened NETosis and N2 reparative neutrophil presence. Spatial transcriptomic analysis confirmed the correlation between glomerular hypoxia and neutrophil extracellular trap (NET) formation. The renal pathology activity index was highly correlated with hypoxic neutrophil count, and these parameters correlated with glomerular endothelial rarefaction and reduced capillary lengths, junctions, and branching. Urinary neutrophil cargo and NET proteins (MPO and proteinase 3) were also elevated in active LN. CONCLUSION: We posit that glomerular endothelial cell damage leads to hypoxia in LN, resulting in hypoxic, reparative myeloid cells and NETosis, whereas the latter has been linked to downstream inflammation and in situ trapping of antinuclear antibodies in LN. These glomerular events underpin high renal pathology activity and may pave the path toward irreversible damage in LN. Detection of neutrophil cargo in urine supports the potential for a liquid biopsy to monitor disease progression.