Venetoclax combined with ML385 overcomes chemotherapy resistance in acute myeloid leukemia by modulating Nrf2/ARE-mediated oxidative stress

Abstract

This study aimed to investigate the potential of Venetoclax combined with ML385 to overcome drug resistance in leukemia cells and the related mechanisms. Analysis of Nrf2 expression and its prognostic significance in AML was performed utilizing the GEO and GEPIA2 databases. Bone marrow specimens were collected from newly diagnosed AML patients to evaluate Nrf2 expression levels and assess their correlation with established risk stratification and clinical prognosis. Two doxorubicin-resistant leukemia cell lines were established. Subsequently, stable Nrf2-knockdown cell lines were generated via lentiviral transduction. Cellular proliferation and apoptosis were analyzed. Levels of reactive oxygen species (ROS) and glutathione (GSH), alongside the expression of oxidative stress-related and apoptosis-related genes and proteins, were quantified. Furthermore, the effects of Venetoclax combined with ML385 on proliferation, apoptosis, ROS levels, and GSH levels were subsequently investigated in these doxorubicin-resistant cell lines. Mechanistically, the impact of the drug combination on oxidative stress and the PI3K/AKT signaling pathway was explored. Nrf2 was up-regulated in AML and predicted poor prognosis. In doxorubicin-resistant AML cells, oxidative-stress genes were elevated. Silencing Nrf2 inhibited proliferation, induced apoptosis, lowered GSH, raised ROS, increased pro-apoptotic BAX and Caspase-3, and decreased anti-apoptotic Bcl-2. Combining the venetoclax with ML385 significantly suppressed proliferation and induced apoptosis in drug-resistant leukemia cells. Mechanistically, this dual-targeting regimen concurrently attenuated both the Nrf2-mediated antioxidant defense and the pro-survival PI3K/AKT signaling axis, which collectively underpin its enhanced anti-leukemic efficacy. This study demonstrates venetoclax combined with ML385 overcomes chemotherapy resistance in acute myeloid leukemia by modulating Nrf2/ARE-mediated oxidative stress.These findings reveal a novel mechanism and a promising therapeutic strategy.

Keywords: Acute myeloid leukemia; ML385; Nrf2/ARE; Oxidative stress; Resistance; Venetoclax.