Abstract 4666: Unraveling the role of Nrf2 in the acute myeloid leukemia: implication for therapeutic targeting

Abstract Background: Acute myeloid leukemia (AML) is a hematologic malignancy characterized by uncontrolled proliferation of myeloid precursor cells, presenting significant therapeutic challenges. NRF2 (Nuclear factor erythroid 2-related factor 2) is a transcription factor that regulates cellular defense mechanisms against oxidative stress, which may contribute to AML progression and chemoresistance. Aim: This study aims to investigate the expression and regulatory role of NRF2 in AML, identify its downstream target genes, and evaluate its contribution to disease progression and chemoresistance. Methods: NRF2 expression was analyzed in de novo AML bone marrow samples, including adult (n=268) and pediatric (n=173) cases, alongside healthy controls (n=45), using qPCR. AML cell lines (MOLM13 and MV411) were also evaluated for NRF2 mRNA and protein expression. Protein levels of NRF2 in AML patient samples and cell lines were assessed via flow cytometry. ChIP sequencing was conducted to identify NRF2 downstream targets, with ChIP-PCR used for target validation. The cytotoxic effects of a chemotherapeutic agent (Daunorubicin) and an NRF2 inhibitor (Brusatol) were assessed using MTT assays to determine the IC50 values. Drug assays and inhibition studies were performed to evaluate the effects of NRF2 inhibition on target gene expression. Statistical analyses, including univariate and multivariate Cox regression, were conducted to correlate NRF2 expression and clinical parameters with patient survival. Results: NRF2 mRNA expression was significantly elevated in de novo AML samples compared to controls (p=0.0024 in adults, p=0.001 in pediatrics). Similarly, high NRF2 expression was observed in MOLM13 and MV411 cell lines. Flow cytometry analysis revealed higher NRF2 protein levels in CD33-positive AML blast cells than in lymphoid cells. ChIP sequencing identified 95 enriched regions associated with NRF2, including genes involved in the HALLMARK Reactive Oxygen Species Pathway, such as NQO1. ChIP-PCR confirmed the significant enrichment of NRF2 target genes, including NQO1, HO1, DAD1, STAT2, and CYP1B1. Treatment with Daunorubicin significantly increased NRF2 expression, while Brusatol significantly reduced NRF2 and its target gene expression (e.g., DAD1, STAT2, and CYP1B1). Survival analyses showed that higher NRF2 mRNA expression was associated with poorer overall survival (p=0.044 in adults, p=0.037 in pediatrics). Multivariate Cox regression analysis indicated that elevated NRF2 expression (HR=1.49, 95% CI=1.10-2.12, p=0.05) and higher WBC counts (HR=1.55, 95% CI=1.06-2.25, p=0.02) were independently associated with poor survival outcomes. Conclusion: This study underscores the role of NRF2 in AML progression and its potential as a biomarker of poor prognosis. Targeting NRF2 and its downstream pathways could provide a novel therapeutic approach to improve outcomes in AML patients. Citation Format: Avanish Kumar Pandey, Neha Thukral, Jay Singh, Mercilena Benjamin, Anmol Gaur, Pranay Tanwar, Jayantha Kumar, Sameer Bakhshi, Surender K. Sharawat, Deepam Pushpam, Akash Kumar, Karthikeyan Pethusamy, Anita Chopra. Unraveling the role of Nrf2 in the acute myeloid leukemia: implication for therapeutic targeting [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 4666.