Augmentation of NAD+ by NQO1 attenuates cisplatin-mediated hearing impairment

Cisplatin (cis-diaminedichloroplatinum-II) is an extensively used chemotherapeutic agent, and one of its most adverse effects is ototoxicity. A number of studies have demonstrated that these effects are related to oxidative stress and DNA damage. However, the precise mechanism underlying cisplatin-associated ototoxicity is still unclear. The cofactor nicotinamide adenine dinucleotide (NAD⁺) has emerged as a key regulator of cellular energy metabolism and homeostasis. Here, we demonstrate for the first time that, in cisplatin-mediated ototoxicity, the levels and activities of SIRT1 are suppressed by the reduction of intracellular NAD⁺ levels. We provide evidence that the decrease in SIRT1 activity and expression facilitated by increasing poly(ADP-ribose) transferase (PARP)-1 activation and microRNA-34a through p53 activation aggravates cisplatin-mediated ototoxicity. Moreover, we show that the induction of cellular NAD⁺ levels using β-lapachone (β-Lap), whose intracellular target is NQO1, prevents the toxic effects of cisplatin through the regulation of PARP-1 and SIRT1 activity. These results suggest that direct modulation of cellular NAD⁺ levels by pharmacological agents could be a promising therapeutic approach for protection from cisplatin-induced ototoxicity.Cisplatin (cis-diamminedichloroplatinum (II)) is a chemotherapeutic agent extensively used to treat a variety of solid tumors in the head and neck, bladder, lung, ovaries, testicles, and uterus.¹ However, progressive irreversible side effects of cisplatin, including nephrotoxicity and ototoxicity, greatly impair the patient''s quality of life and frequently result in the need to lower the dosage during treatment or discontinuation of the treatment. Cisplatin ototoxicity primarily occurs in the cochlea and is generally caused by apoptotic damage to the outer hair cells (OHCs), spiral ganglion cells, and the marginal cells of the stria vascularis. In recent years, studies have demonstrated that cisplatin ototoxicity is also closely related to the damage of cochlear tissue by increased production of reactive oxygen species (ROS) and accompanied by the depletion of antioxidant substances and increased lipid peroxidation.^{2, 3} ROSs, particularly the hydroxyl radical, have a critical role in cisplatin-induced p53 activation through DNA damage.⁴ Although it is not easy to differentiate the cause from the consequence, a positive feedback loop between inflammatory cytokines and oxidative stress that worsen the cochlear damage is considered as one of the major mechanisms that facilitate cisplatin-induced hearing impairment.⁵ Interestingly, p53 and NF-κB have been described as key mediators of cisplatin-induced toxicity because of their involvement in oxidative stress, DNA damage, and inflammation through a mutual feedback process of ‘cause and effect.''^{6, 7} In addition, activities of p53 and NF-κB could be regulated by post-translational modifications, including phosphorylation and acetylation. Recent studies have reported that acetylated p53 and NF-κB are correlated with cisplatin-induced toxicity. Furthermore, acetylation of p53 and NF-κB is critically involved in cisplatin-induced renal injury.^{8, 9}Cellular nicotinamide adenine dinucleotide (NAD⁺) and NADH levels have been shown to be important mediators of energy metabolism and cellular homeostasis.^{10, 11} As NAD⁺ acts as a cofactor for various enzymes, including sirtuins (SIRTs), poly(ADP-ribose) transferases (PARPs), and cyclic ADP (cADP)-ribose synthases,^{12, 13} the regulation of NAD⁺ level may have therapeutic benefits through its effect on NAD⁺-dependent enzymes. SIRTs, NAD⁺-dependent protein deacetylases, are present as seven homologs of Sir2 (SIRT1-7) that show differential subcellular localizations in mammals.¹¹ Among these, nuclear SIRT1 is activated under energy stress conditions, such as fasting, exercise, or low glucose availability. ¹⁴ SIRT1 has a key role in metabolism, development, stress response, neurogenesis, hormone responses, and apoptosis^{15, 16} by deacetylation of substrates, such as NF-κB, FOXO, p53, and histones.^{17, 18, 19}PARPs, the most abundant ADP-ribosyl transferases, also use NAD⁺ to generate large amounts of poly(ADP-ribose) (PAR), which facilitate the recruitment of DNA repair factors. In particular, PARP-1 is a DNA damage sensor that can be activated in response to DNA damage by various pathophysiological conditions, including oxidative stress and inflammatory injury. However, excessive hyperactivation of PARP-1 causes the depletion of intracellular NAD⁺ and ATP levels, which eventually leads to cell death.^{20, 21} PARP-1 activation is also known as one of the important pathogenic mechanisms in cisplatin-induced toxicity.^{22, 23}A cytosolic antioxidant flavoprotein NADH:quinone oxidoreductase 1 (NQO1) catalyzes the reduction of quinones to hydroquinones by utilizing NADH as an electron donor, which consequently increases intracellular NAD⁺ levels.^{24, 25} In addition, accumulation evidence suggests that NQO1 has a role in other biological activities, including anti-inflammatory processes, scavenging of superoxide anion radicals, and stabilization of p53 and other tumor suppressor proteins.^{26, 27, 28} Several substrates of NQO1 enzyme, including mitomycin C, RH1, AZQ, Coenzyme Q10, and idebenone, have been identified,^{29, 30} of which β-lapachone (3,4-dihydro-2,2-dimethyl-2H-naphtho[1,2-b]pyran-5,6-dione; β-Lap) is recently well studied as a substrate of NQO1.^{31, 32} β-Lap was first isolated from the bark of the lapacho tree and reported to inhibit tumor cell line growth.³³ However, recent reports indicate that the conversion of NADH to NAD⁺ by NQO1 and β-Lap has beneficial effects on several characteristics of metabolic syndrome, for example, prevention of health decline in aged mice, amelioration of obesity or hypertension, prevention of arterial restenosis, and protection against salt-induced renal injury.^{34, 35, 36, 37, 38} Furthermore, we recently have demonstrated that conversion of NADH to NAD+ by NQO1 and β-Lap suppresses cisplatin-induced acute kidney injury by downregulating potential damage mediators such as oxidative stress and inflammatory responses.⁹Although a link between NAD⁺-dependent molecular events and cellular metabolism is evident, it remains unclear whether modulation of NAD⁺ levels has an impact on cisplatin-induced hearing impairment. Therefore, herein we investigated the role of NAD⁺ metabolism on cisplatin-induced cochlear dysfunction, and the effect of increased levels of intracellular NAD⁺ facilitated by β-Lap on cisplatin-induced hearing impairment with a particular interest in NAD⁺-dependent enzymatic pathways including SIRTs and PARPs.