Autophagy-dependent hepatocyte apoptosis mediates gilteritinib-induced hepatotoxicity

Gilteritinib, a dual FLT3/AXL inhibitor, is clinically effective for relapsed/refractory FLT3-mutated acute myeloid leukemia (AML) but is limited by severe hepatotoxicity. This study investigates the molecular mechanisms underlying gilteritinib-induced liver injury, focusing on the interplay between autophagy and apoptosis. In vitro and in vivo models, including human hepatocyte HL-7702 cells and C57BL/6 J mice, were employed. Gilteritinib treatment significantly upregulated autophagy markers (LC3-II) and induced autophagosome formation, as confirmed by western blot, TEM, and mCherry-GFP-LC3 reporter assays. Concurrently, apoptosis markers (cleaved-PARP, cleaved-Caspase3, Annexin V/PI staining) increased dose- and time-dependently. Pharmacological inhibition of autophagy with autophagy inhibitor 3-methyladenine (3-MA, 5 mM) or gene silence of Atg7 attenuated apoptosis, mitochondrial membrane potential loss, and ROS overproduction, while autophagy induction by Torin1 (100 nM) exacerbated hepatocyte death. In vivo, gilteritinib-treated mice exhibited elevated serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) levels, alongside histopathological damage, all of which were mitigated in Atg7-deficient mice. These findings demonstrate that gilteritinib triggers excessive autophagy, which drives hepatocyte apoptosis and liver injury. Targeting autophagy pathways, represents a potential therapeutic strategy to alleviate gilteritinib-induced hepatotoxicity, enabling safer clinical use of this vital AML therapy. This study elucidates a critical autophagy-apoptosis axis in drug-induced liver injury and provides actionable insights for managing adverse effects of targeted cancer therapies.