From Defense to Dysfunction: Decoding the Paradox of Emergency Granulopoiesis in Sepsis Pathogenesis

Sepsis is a life-threatening syndrome caused by dysregulated host response that culminates in organ dysfunction. Recognizing that many prior reviews treated neutrophils as largely homogeneous or discussed their functions in isolation, we present a framework centered on emergency granulopoiesis that unifies groundbreaking single-cell multi-omics discoveries, bone marrow niche remodeling, and bedside biomarkers such as the immature-to-total neutrophil ratio and sepsis endotypes to explain the shift from defense to dysfunction. As a hallmark adaptation, emergency granulopoiesis rapidly replenishes neutrophils but paradoxically yields immature neutrophils with impaired chemotaxis, excessive neutrophil extracellular trap formation (NETosis)/reactive oxygen species, and immunosuppressive activity that aggravate tissue damage, organ failure, and late immunoparalysis. We synthesize subset-level diversity and map this diversity to transcriptional shifts coupled with epigenetic and metabolic reprogramming as well as stromal inflammation. Clinically, elevated immature-to-total neutrophil ratios and these immature subsets align with disease severity and mortality, supporting biomarker-guided stratification. Stage-specific therapeutic strategies are evaluated along the continuum of emergency granulopoiesis, calibrating NETosis, and modulating metabolic reprogramming and epigenetics to restore neutrophil homeostasis. Furthermore, we delineate testable priorities for future research such as standardizing immature neutrophil phenotyping across cohorts and defining harmonized immature-to-total neutrophil ratio thresholds. By explicitly centering emergency granulopoiesis and integrating single-cell biology with bedside indicators, this review clarifies why a protective program becomes maladaptive in sepsis and outlines practical avenues for targeted interventions and trial design.