Targeting MTHFD2 disrupts mitochondrial redox homeostasis and restores venetoclax sensitivity in acute myeloid leukemia

Abstract One-carbon metabolism is frequently dysregulated in human cancer including acute myeloid leukemia. However, the mitochondrial mechanisms by which one-carbon enzymes support leukemia survival and therapeutic response remain incompletely defined. Here, we report that the one-carbon metabolism enzyme MTHFD2 is a critical regulator of acute myeloid leukemia nucleotide metabolism, redox homeostasis, and disease progression. We show that genetic ablation of MTHFD2 suppresses acute myeloid leukemia cell proliferation in vitro and significantly delays leukemia onset in a genetically engineered mouse model, while sparing healthy hematopoietic stem and progenitor cell function. Stable isotope tracing demonstrates that MTHFD2 supports de novo purine synthesis and sustains mitochondrial NADH and NADPH production. Consistent with this role, MTHFD2 inhibition increases mitochondrial superoxide levels, and combined purine supplementation and mitochondrial reactive oxygen species neutralization rescues acute myeloid leukemia cell viability. We also demonstrate that the small-molecule inhibitor DS18561882 directly inhibits mitochondrial MTHFD2 activity and phenocopies genetic deletion. DS18561882 exhibits activity across a cohort of 60 primary AML patient samples, synergizes with venetoclax in treatment-naïve acute myeloid leukemia, and restores venetoclax sensitivity in resistant AML models. These findings establish mitochondrial MTHFD2 as a genetically validated, therapeutically targetable metabolic vulnerability in acute myeloid leukemia and support targeting mitochondrial one-carbon metabolism to enhance and restore venetoclax response.