NINJ1 is activated by calcium-driven plasma membrane lipid scrambling during lytic cell death

NINJ1 is the terminal executioner of cellular rupture in multiple lytic cell death pathways through its clustering in the plasma membrane. Its activation trigger, however, remains unknown. We found that NINJ1-mediated plasma membrane rupture depends on calcium influx into the cell, which suffices to induce NINJ1-mediated rupture. Using genetic and pharmacologic approaches in macrophages, we show calcium drives membrane rupture through phospholipid scrambling by the calcium-activated scramblase TMEM16F. We next tested whether this calcium-activated NINJ1 mechanism is the elusive pathway by which extracellular ATP stimulates cellular rupture. We show that ATP-stimulation of P2X7R induces NINJ1-mediated cell lysis via calcium influx and TMEM16F lipid scrambling, independently of inflammasomes, pannexins and gasdermin D. Our work reveals the mechanism of NINJ1 activation and solves the long-standing mystery of ATP-induced cytolysis.