Why is the tumor microenvironment disordered by NADH/NAD(+) imbalance and how can we intervene?

Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Redox Biol . 2026 Mar 27;92:104145. doi: 10.1016/j.redox.2026.104145 Search in PMC Search in PubMed View in NLM Catalog Add to search Why is the tumor microenvironment disordered by NADH/NAD + imbalance and how can we intervene? Jing Li Jing Li e Department of Oncology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, 361000, China Find articles by Jing Li e, 1 , Tong Zhang Tong Zhang c Organ Transplantation Institute of Xiamen University, Xiamen Human Organ Transplantation Quality Control Center, Xiamen Key Laboratory of Regeneration Medicine, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361000, China Find articles by Tong Zhang c, 1 , Tianrong Ma Tianrong Ma a Department of Gastrointestinal Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, 361000, China Find articles by Tianrong Ma a, 1 , Tao Chen Tao Chen d Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, Jiangxi, 341000, China Find articles by Tao Chen d, ⁎ , Xianzhi Liu Xianzhi Liu b Department of Gastroenterology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, 361000, China Find articles by Xianzhi Liu b, ⁎⁎, 1 , Weiling He Weiling He a Department of Gastrointestinal Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, 361000, China Find articles by Weiling He a, ⁎⁎⁎ Author information Article notes Copyright and License information a Department of Gastrointestinal Surgery, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, 361000, China b Department of Gastroenterology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, 361000, China c Organ Transplantation Institute of Xiamen University, Xiamen Human Organ Transplantation Quality Control Center, Xiamen Key Laboratory of Regeneration Medicine, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361000, China d Department of Gastrointestinal and Hernia Surgery, Ganzhou Hospital-Nanfang Hospital, Southern Medical University, Ganzhou, Jiangxi, 341000, China e Department of Oncology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, 361000, China ⁎ Corresponding author. [email protected] ⁎⁎ Corresponding author. [email protected] ⁎⁎⁎ Corresponding author. [email protected] 1 These authors contributed equally. Received 2026 Mar 24; Accepted 2026 Mar 26; Collection date 2026 May. © 2026 The Authors This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). PMC Copyright notice PMCID: PMC13066797  PMID: 41911638 Abstract NADH and NAD + are crucial redox cofactors in biological systems, participating in the mitochondrial respiratory chain and playing significant roles in various metabolic processes. Increasing evidence indicates that changes in the NADH/NAD + ratio play a critical role in tumor biology. In this review, we focus on the physiological functions of the NADH/NAD + redox couple and its core role in tumor initiation and progression, and we further examine the key mechanisms of NADH/NAD + ratio imbalance during tumor development, including metabolic reprogramming and interactions with the immune microenvironment. Finally, we summarize the emerging therapeutic strategies targeting the NADH/NAD + ratio from the perspective of regulating NADH and NAD + synthesis, shuttling, and metabolic microenvironment. These insights provide a theoretical framework and promising directions for the development of novel NADH/NAD + -targeted anti-tumor therapies. Keywords: NADH/NAD + , Tumor metabolism, Mitochondria, Tumor immunity, Anti-Tumor therapy 1. Introduction The reduced form of nicotinamide adenine dinucleotide (NADH) is a key mediator of antioxidant defense and cellular detoxification. Its oxidized counterpart, nicotinamide adenine dinucleotide (NAD + ), functions as an essential intracellular cofactor and also plays an important role in rapidly proliferating cells [ 1 , 2 ]. In vivo, NAD + and NADH can be converted into each other. NAD + acts as an electron acceptor and is reduced to NADH during glycolysis, the tricarboxylic acid cycle (TCA cycle), and oxidative phosphorylation. NADH then transfers electrons to oxygen via the electron transport chain, ultimately generating ATP and supplying energy to the cell [ 3 , 4 ]. In addition, changes in the NADH/NAD + ratio play an important role in regulating mitochondrial membrane potential, maintaining normal mitochondrial function, modulating oxidative stress and reductive stress, and influencing cell senescence and apoptosis [ [5] , [6] , [7] , [8] , [9] , [10] ]. A decreased NADH/NAD + ratio in tumor cells can promote cancer progression, whereas an increased ratio may inhibit tumor growth. The NADH/NAD + ratio is also regulated by tumor metabolic reprogramming [ [11] , [12] , [13] , [14] ]. Meanwhile, alterations in the NADH/NAD + ratio can reshape the tumor microenvironment and impair immune cell function, enabling tumor cells to evade immune recognition and clearance [ 15 ]. The NADH/NAD + balance in tumor cells is regulated by multiple factors that influence tumor initiation and progression, and it can further modulate tumor progression through regulation of CtBP activity [ [16] , [17] , [18] ]. Since NADH/NAD + plays an important role in the regulation of tumors, targeting NADH/NAD + is currently an emerging therapeutic strategy in cancer treatment. For example, oxaliplatin, a therapeutic drug for gastric cancer, can promote the apoptosis of tumor cells by targeting NADH oxidase, and recent studies have developed nanozymes targeting NADH/NAD + , which exhibit inhibitory effects on tumor progression [ 19 , 20 ]. Therefore, this article mainly describes the effects of alterations in the NADH/NAD + ratio on tumor progression and the specific regulatory mechanisms, and explores the therapeutic potential of targeting NADH/NAD + in cancer, which may provide new strategies for tumor treatment. 2. Physiological functions of NADH/NAD + 2.1. Biosynthesis of NAD + and NADH Reduced nicotinamide adenine dinucleotide (NADH) and oxidized nicotinamide adenine dinucleotide (NAD + ) constitute a pair of essential intracellular redox coenzymes and are important mediators of cellular processes [ 21 ]. In the human body, the synthesis of NAD + is mainly achieved through three pathways: the de novo synthesis pathway, the Preiss–Handler pathway, and the salvage synthesis pathway. In the de novo synthesis pathway, tryptophan (TRP) is first converted into N-formyl kynurenine (NFK) by the action of indoleamine 2,3-dioxygenase 1, 2 (IDO1, 2) or tryptophan 2,3-dioxygenase (TDO2) (tryptophan 2,3-dioxygenase). Subsequently, NFK is deacylated by the action of aromatic amide hydrolase (AFMID) to generate kynurenine (KYN), which is a key node in the tryptophan metabolic process. KYN is then converted by mitochondrial-related enzymes - kynurenine 3-monooxygenase (KMO) into 3-hydroxykynurenine (3HK). 3HK is catalyzed by kynureninease (KYNU) to generate 3-hydroxy-4-aminophenylacetic acid (3HAA), which is further catalyzed by 3HAA dioxygenase (HAAO) to convert into 2-amino-3-carboxymuconic semialdehyde (ACMSA) (2-amino-3-carboxymuconic semialdehyde). ACMSA can spontaneously react to form quinolinic acid (QA). QA is converted by QA phosphoribosyltransferase (QPRT) into the precursor of NAD + - nicotinamide mononucleotide (NAMN). NAMN is formed by NMN adenylyltransferase (NMNATs) into nicotinamide adenine dinucleotide (NAAD). Finally, NAAD is converted into NAD + by NAD + synthase through NAAD [ 22 ]. Nicotinic acid can also be converted into NAD + via the Preiss–Handler pathway. The process is as follows: nicotinic acid first enters the cytoplasm through a monocarboxylate transporter, and then is converted into nicotinamide mononucleotide (NAMN) under the catalysis of nicotinamide phosphoribosyltransferase (NAPRT). NAMN is then converted into NAAD under the action of NMNAT1-3, and finally further synthesized into NAD + under the catalysis of NADSYN. The salvage synthesis pathway is the main way for NAD + synthesis in the human body, mainly utilizing endogenous nicotinamide (NAM) as the substrate. In this pathway, NAM is generated into nicotinamide mononucleotide (NMN) under the catalysis of the rate-limiting enzyme NAMPT, and then directly converted into NAD + under the catalysis of NMNAT. Nicotinamide riboside (NR), as a newly discovered NAD + precursor, can also participate in the salvage synthesis pathway. Extracellular NMN is converted by CD73 into nicotinamide riboside (NR), which is then transported into the cell through SLC29A1-encoded equilibrative nucleoside transporter 1 (ENT1). Intracellularly, NR is converted into NMN by nicotinamide riboside kinase, and NMN is subsequently converted into NAD + by NMNAT [ 23 , 24 ] ( Fig. 1 ). Fig. 1. Open in a new tab Biosynthetic pathways of NAD + and NADH. NAD + is synthesized primarily through the de novo, Preiss–Handler, and salvage pathways, whereas NADH is mainly generated by the reduction of NAD + . In humans, the salvage synthesis pathway is the primary way to maintain the level of NAD + , mainly by recycling the NAD + that is consumed daily. This pathway is particularly active in metabolically active tissues and when cells are in states such as aging or stress [ 25 , 26 ]. When vitamin B3 is consumed through diet, or when a large amount of nicotinic acid is ingested due to the use of lipid-lowering drugs, the body mainly relies on the Preiss–Handler pathway to generate NAD + . The key enzyme NAPRT in this pathway has a relatively high expression level in the liver, kidneys, and intestines. Therefore, in these organs, the Preiss–Handler pathway is an important way to maintain the stability of NAD + [ [27] , [28] , [29] ]. The de novo synthesis pathway of NAD + is mainly activated when there is an adequate supply of tryptophan or when the body is in an inflammatory state. It is the main way for the liver to synthesize NAD + , and it becomes more significant especially after fasting or after a high-protein diet [ 30 , 31 ]. NADH is an important reducing equivalent in the body and is mainly derived from the reduction of NAD + during metabolic processes. NADH is produced via two main pathways, glycolysis and the tricarboxylic acid cycle. In glycolysis, glyceraldehyde-3-phosphate dehydrogenase (GAPDH) catalyzes the reduction of NAD + to produce NADH; whereas in the tricarboxylic acid cycle, isocitrate dehydrogenase (IDH), α-ketoglutarate dehydrogenase (α-KGDH), and malate dehydrogenase 2 (MDH2) undertake the main function of reducing NAD + to NADH. It is worth noting that even under aerobic conditions, many tumor cells still tend to rely on glycolysis for energy supply, resulting in the NADH accumulation—a phenomenon known as the Warburg effect [ 32 , 33 ]. In summary, NAD + is mainly synthesized through three pathways: de novo synthesis from tryptophan, the Preiss–Handler pathway, and the salvage pathway. While NADH is generated by the reduction of NAD + during glycolysis and the tricarboxylic acid cycle and the Warburg effect in tumor cells contributes to the abnormal accumulation of NADH. 2.2. The function of NADH and NAD + NAD + and NADH perform distinct functions depending on their subcellular localization. NAD + is widely distributed in mitochondria, the nucleus, the cytoplasm, and the extracellular space, with the highest content found in mitochondria. Mitochondrial NAD + can be transported from the cytoplasm or synthesized locally in the mitochondrial matrix to meet the basic energy demands for cell growth, proliferation, and survival. In the nucleus, NAD + mainly functions by participating in the ADP-ribosylation process mediated by PARP and serving as a substrate for Sirtuins (SIRTs) to drive deacetylation reactions. In the cytoplasm, NAD + acts as a central metabolic hub linking redox processes across subcellular compartments, with its levels locally regulated by NMNAT1 and NMNAT2, and it plays a crucial role in glycolysis. Extracellular NAD + can be released during cell damage or lysis and may contribute to replenishing intracellular NAD + levels [ 34 ]. NADH is also distributed in mitochondria, the cell nucleus and the cytoplasm. The NADH in mitochondria is mainly generated by the reduction of NAD + through isocitrate dehydrogenase 3 (IDH3), alpha-ketoglutarate dehydrogenase (KGDH) and malate dehydrogenase 2 (MDH2). Compared with nuclear NADH, cytoplasmic NADH is more sensitive to fluctuations in the cellular environment [ 35 ]. NAD + and NADH maintain a dynamic equilibrium in the body and jointly regulate cellular metabolism. During glycolysis, NAD + can act as an electron acceptor and is reduced to form NADH. The NADH produced by glycolysis and the tricarboxylic acid cycle enters the oxidative phosphorylation pathway under aerobic conditions. Through the mitochondrial respiratory chain, ATP is generated while NAD + is regenerated, providing energy for the body. In the absence of oxygen, the NADH produced by glycolysis participates in the lactate fermentation process, mediating the reduction of pyruvate to lactate, and simultaneously, NAD + is regenerated, maintaining the continuous progress of glycolysis [ 32 , 36 ]. The dynamic equilibrium between NAD + and NADH depends on the balance between nutrient metabolism and electron transfer efficiency and is tightly regulated by their synthesis and consumption. This balance is critical for maintaining cellular energy homeostasis and metabolic regulation. NADH functions as an electron carrier within the mitochondrial respiratory chain, and its interconversion with NAD + is coupled to proton translocation across the inner mitochondrial membrane. Under physiological conditions, NAD + is reduced to NADH during glycolysis and fatty acid metabolism, and the latter is re-oxidized through the electron transfer chain to regenerate NAD + , simultaneously driving ATP synthesis to maintain the energy homeostasis of the organism. When the function of the electron transfer chain is blocked or hypoxia occurs, the oxidation of NADH is inhibited, which may lead to excessive accumulation of NADH in the body [ 37 , 38 ]. The change in the NADH/NAD + ratio is usually regarded as a sign of mitochondrial dysfunction, reflecting redox imbalance. When this ratio increases, it inhibits the activity of various metabolic enzymes and may also inhibit cell proliferation. At the same time, mitochondria can respond rapidly to external stimuli through fluctuations in the NADH/NAD + ratio, thereby participating in the regulation of the entire metabolic system [ 38 , 39 ]. An excessively high ratio of NADH/NAD + can lead to mitochondrial dysfunction and stress responses. For example, phosphoglycerate dehydrogenase (PHGDH) may promote the production of the oncometabolite 2-hydroxyglutarate (2-HG) from α-ketoglutarate (α-KG), thereby disrupting mitochondrial function [ 7 ]. The NADH/NAD + also plays an important role in the tricarboxylic acid (TCA) cycle. NAD + serves as an essential cofactor for multiple enzymatic reactions, while NADH is a key product of the cycle [ 7 , 40 ]. When NADH accumulates excessively, it can easily trigger oxidative stress promotion and also downregulate the activity of key enzymes in the TCA cycle by inhibiting the activity of the pyruvate dehydrogenase complex (PDH), reducing the generation of intermediate metabolic products in the cycle and affecting energy production [ 41 ]. Studies have found that the soluble adenylyl cyclase-cAMP1 signaling axis can regulate the cytosolic NADH/NAD + redox state by modulating the complex I-dependent mitochondrial respiration of the mitochondrial respiratory chain, coordinating the balance between oxidative phosphorylation and glycolysis, and thereby maintaining the energy homeostasis of the cell [ 42 ]. When the intracellular NAD + level decreases, SIRT1 activity is inhibited, enhancing the stability of HIF-1α, shifting metabolism toward glycolysis, and causing mitochondrial dysfunction [ 43 ]. In addition, when the NADH/NAD + ratio increases under low glycolytic activity, NADH binds to CtBP under the regulation of p53 and NFκB, exerting a global transcriptional inhibitory effect and maintaining cellular homeostasis [ 44 ]. As key regulators of protein acetylation, the NAD + -dependent deacetylases family Sirtuins (SIRTs) play an important role in the fat metabolism process, and their deacetylase activity strictly depends on the level of NAD + [ 39 ]. In the liver, NADH can activate the transcription factor ChREBP, upregulate the expression of genes related to lipid de novo synthesis, and promote the conversion of excess carbohydrates into fat [ 45 ]. During the process of fatty acid oxidation and dehydrogenation, NAD + accepts H + released by fatty acids and generates NADH, which increases the NADH/NAD + ratio and inhibits the continuous oxidation of fatty acids. If this imbalance persists for a long time, it can lead to the accumulation of fat in the liver, forming fatty liver [ 46 ]. In nucleotide metabolism, an increase in the NADH/NAD + ratio can provide the required reducing power for nucleotide synthesis. Additionally, NADH is also involved in activating enzymes such as DNA polymerase and DNA ligase [ 47 ]. In summary, the dynamic equilibrium of NADH/NAD + is the core for maintaining cellular energy metabolism and mitochondrial function. Changes in its ratio directly regulate the activity of the electron transport chain and the TCA efficiency. An elevated ratio promotes reductive stress and metabolic inhibition, whereas a decreased ratio may impair p53/NF-κB–mediated genomic surveillance, leading to genomic instability. Additionally, this ratio also integrates sugar, lipid, and nucleotide metabolism through modulation of Sirtuins and key lipogenic regulators such as ChREBP, enabling cells to adapt to their energetic state ( Fig. 2 ). Fig. 2. Open in a new tab Functions of NADH/NAD + . An elevated NADH/NAD + ratio can increase mitochondrial membrane potential, promote ferroptosis, and suppress energy metabolism through inhibition of pyruvate dehydrogenase (PDH). In addition, the accumulation of 2-hydroxyglutarate (2-HG) caused by an increased NADH/NAD + ratio may impair mitochondrial function, and an elevated NADH/NAD + ratio may also disrupt cellular homeostasis. 2.3. Factors regulating NADH/NAD + in vivo The NADH/NAD + ratio is regulated in vivo by a variety of factors, most of which involve mitochondria. For example, in mitochondria, the NADH/NAD + ratio is regulated by the concentration of calcium in mitochondria, and a decrease in calcium concentration will increase the NADH/NAD + ratio by inhibiting ATP synthesis, leading to reducing stress in vivo [ 48 ]. When the mitochondrial function is reduced and the conversion of NADH to NAD + is inhibited, extracellular pyruvate can interact with NADH through lactate dehydrogenase to produce lactate and NAD + , and maintain the stability of NADH/NAD + ratio in vivo. Hypoxia-inducible factor-1α (HIF1α) can increase the NADH/NAD + ratio by attenuating mitochondrial oxygen consumption [ 11 ]. Dysregulation of the pyruvate dehydrogenase complex (PDH) can impair mitochondrial electron transport and NAD + regeneration, partly through increased mitochondrial membrane potential, thereby elevating the NADH/NAD + ratio, a process that can be mitigated by enhancing mitochondrial respiration, ATP metabolism, and glucose oxidation [ 49 ]. Mitochondrial enzymes also influence the NADH/NAD + ratio. For instance, deficiency of mitochondrial serine hydroxymethyl transferase (SHMT2) will result in a decrease in the ratios of NADH/NAD + , NADPH/NADP + , and GSH/GSSG, which will lead to the loss of mitochondrial membrane potential and subsequently damage the function of mitochondria [ 50 ]. In the case of obvious mitochondrial dysfunction, bioenergy will be depleted, which will lead to a significant reduction in the content of NADH and NAD + , and the reduction of glucose integration in the metabolic pathway, resulting in a decrease in the ratio of NADH/NAD + [ 51 ]. In addition to being affected by mitochondrial function, NADH/NAD + is also regulated by other intracellular factors. The synthesis of purine requires a large amount of ATP, and the increase of purine biosynthesis will lead to the excessive accumulation of NADH, resulting in the increase of NADH/NAD + ratio, which will promote the massive energy consumption in the body [ 52 ]. In patients with myocardial iron deficiency (MID) because the ratio of NADH/NAD + is proportional to hypoxia and coronary hypoperfusion, the content of NAD + in the patient's body will be significantly reduced, resulting in the increase of NADH/NAD + ratio. Moreover, the increased NAD + consumption makes cardiomyocytes more susceptible to apoptosis and necrosis [ 53 ]. In summary, the NADH/NAD + ratio is dynamically regulated by multiple factors, such as mitochondrial function ( Ca 2+ levels, PDH activity, and electron transport chain status ), metabolic substrates (pyruvate/lactate), and energy requirements (purine synthesis). Its imbalance can lead to reducing stress or energy failure, thereby affecting cell survival and metabolic homeostasis ( Fig. 3 ). Fig. 3. Open in a new tab Factors regulating NADH/NAD + in the body. Changes in Ca 2+ , PDH, lactate, and pyruvate can all alter the NADH/NAD + ratio. 3. NADH/NAD + dysregulation is involved in the mechanisms of tumorigenesis 3.1. Dysregulation of NADH/NAD + ratio affects cancer progression 3.1.1. Decreased NADH/NAD + ratio promotes cancer progression The imbalance in the NADH/NAD + ratio plays an important role in tumor progression. Increased synthesis of NAD + leads to a decrease in the NADH/NAD + ratio in the cells. This can promote citrate synthesis and the generation of oxidized and reduced lipids, thereby further stimulating lipid production to promote the proliferation of cancer cells [ 54 ]. In pancreatic cancer, it has been shown that acetylation of three lysine residues on GOT2 in mitochondria promotes a net transfer of cytosolic NADH to the mitochondria, thereby decreasing the cytosolic NADH/NAD + ratio and promoting ATP production. At the same time, acetylation of these three lysine residues can also promote the production of NADPH, inhibit the excessive accumulation of ROS, protect tumor cells from oxidative damage, and promote the progression of pancreatic cancer [ 12 ]. In an acidic environment, the study found that nuclear factor I B (NFIB) inhibits the expression of miRNA-182-5p, leading to increased NAMPT levels. This promotes NAD + production, reduces the NADH/NAD + ratio, and thereby facilitates the progression of colorectal cancer [ 55 ]. Studies have shown that in human colorectal cancer, there exists a B cell subgroup (LARS B cells) expressing leucine-tRNA-synthase-2 (LARS2) within the immunomodulatory B cells. LARS2 can promote the regeneration of NAD + by regulating complex I in the mitochondrial respiratory chain, thereby facilitating the transfer of NADH from the cytoplasm to the mitochondria and reducing the cytoplasmic NADH/NAD + ratio. At the same time, NAD + can promote the production of TGF-β1 in LARS B cells through SIRT1, thereby facilitating immune escape and promoting colorectal cancer progression [ 56 ]. The C-terminal binding protein (CtBP) is a global co-repressor protein that plays a crucial role in maintaining the cellular homeostasis. CtBP is NADH-dependent, and its function and activity vary depending on the ratio of NADH/NAD + within the cell. When the intracellular NADH/NAD + ratio is high, CtBP exists in a dimeric form; conversely, when the ratio is low, it exists in a monomeric form [ 44 , 57 ]. When the ratio of NADH/NAD + decreases and the efficiency of glycolysis is high, the monomeric form of CtBPs binds to HDM2, a regulator of p53, thereby inhibiting p53 activity. The monomeric form of CtBPs can also inhibit the transcription of NFkB. These events disrupt cellular homeostasis, promote carcinogenesis, and accelerate cancer progression [ 18 , 44 ] ( Fig. 4 ). Fig. 4. Open in a new tab A decreased NADH/NAD + ratio promotes cancer progression. In pancreatic cancer, GOT acetylation facilitates NADH transfer into mitochondria, lowers the intracellular NADH/NAD + ratio, and enhances ATP production. Under acidic conditions, NFIB suppresses miR-182-5p, upregulates NAMPT, and decreases the NADH/NAD + ratio, thereby promoting colorectal cancer progression. Under highly glycolytic conditions, a reduced NADH/NAD + ratio favors the monomeric form of CtBP, which inhibits NF-κB and p53, disrupts intracellular homeostasis, and promotes carcinogenesis. 3.1.2. Increased NADH/NAD + ratio inhibits cancer progression An increase in the NADH/NAD + ratio not only disrupts the function of the mitochondrial electron transport chain but also leads to the accumulation of ROS in the body, thereby disrupting the cellular homeostasis. Lactate dehydrogenase is composed of two subunits, LDH-A and LDH-B. LDH-A catalyzes the combination of pyruvate with NADH to form lactate and NAD + . In tumor cells, when the activity of LDH-A decreases, the conversion of NADH to NAD + is inhibited, resulting in an increase in the NADH/NAD + ratio. This reduces the membrane potential of the mitochondria and weakens the proliferation of cancer cells [ 58 , 59 ]. When the supply of pyruvate is limited, HIF1α within tumor cells can induce an increase in the HIF1α-dependent NADH/NAD + ratio, thereby inhibiting the proliferation of tumor cells by suppressing the activity of GAPDH [ 11 ]. Studies have shown that in various types of cancer, NRF2 can regulate oxidative stress by modulating KEAP1. This is achieved by regulating the oxidative capacity of NADH. In non-small cell lung cancer, inhibiting mitochondrial complex I can block the oxidation of NADH, causing an excessively high NADH/NAD + ratio. This leads to lethal reductive stress in lung cancer cells with mutated KEAP1 and a low glycolytic activity, thereby inhibiting the progression of cancer [ 1 , 60 ]. In ovarian cancer cells, the deficiency of 75-kDa glucose-regulated protein (GRP75) disrupts the integrity of endoplasmic reticulum membranes and inhibits the transfer of calcium from endoplasmic reticulum to mitochondria. In turn, cisplatin will promote the destruction of mitochondrial function, resulting in decreased NAD + content in cells. A high NADH/NAD + ratio triggers catastrophic ROS accumulation in vivo, and enhances cisplatin-induced apoptosis in ovarian cancer cells [ 61 ]. In glioma cells, deoxypodophyllotoxin (DPT) reduces intracellular NAD + levels, leading to an increase in the NADH/NAD + ratio. This change, on one hand, exacerbates DNA double-strand breaks by upregulating NADPH oxidase 2 (NOX2) in a reactive oxygen species (ROS)-dependent manner. on the other hand, it promotes acetylation of PARP1 by increasing the expression of N-acetyltransferase 10 (NAT10). The combined effect results in excessive activation of PARP1, ultimately inducing Parthanatos, a form of programmed cell death [ 62 ]. Deficiency of Tumor necrosis factor receptor-associated factor 2 (TRAF2) stimulates Reactive oxygen species modulator 1 (ROMO1) expression in hepatocellular carcinoma. At the same time, it increases the ratio of NADH/NAD + , which destroys the function of mitochondria, resulting in excessive accumulation of ROS in vivo and DNA damage in liver cancer cells. Furthermore, the p53/p21 WAF1 and p16 INK4a/pRb pathways can induce senescence of liver cancer cells and inhibit the progression of liver cancer [ 63 ]. In glioma cells, AROS-mediated activation of SIRT1 depletes NAD + , leading to an increased NADH/NAD + ratio and subsequent activation of ATF3. Activated ATF3 suppresses SLC7A11 and GPX4 expression, resulting in cysteine and glutathione depletion, increased oxidative stress, and enhanced sensitivity of glioma cells to ferroptosis. When the synthesis of NAD + is inhibited by pharmacologic inhibitors—which results in a reduced NAD + level (i.e., an increase in the ratio of NADH/NAD + )—it further activates AFT3, further enhancing the sensitivity of glioma cells to ferroptosis and inhibiting the progression of glioma [ 64 ]. It has been found that the expression (mRNA and protein) and activity of NADH-dependent transcription regulators CtBP1 and CtBP2 are significantly increased in cancer stem cells (CSCS), which are closely related to tumor recurrence. Part of the reason may be that the NADH/NAD + ratio is higher in these cells, disrupting the homeostasis of the reducing system in vivo [ 65 ]. In summary, the NADH/NAD + ratio plays a dual role in cancer progression by regulating tumor metabolic reprogramming, REDOX homeostasis, and CtBP-dependent transcriptional regulation. It can not only promote proliferation and metastasis, but also induce reductive stress to suppress tumor, and is a potential tumor therapeutic target ( Fig. 5 ). Fig. 5. Open in a new tab An increased NADH/NAD + ratio inhibits cancer progression. In ovarian cancer, loss of GRP75 blocks Ca 2+ entry into mitochondria, enhances cisplatin-induced mitochondrial damage, increases the NADH/NAD + ratio, and promotes ROS accumulation. In glioma, AROS activates SIRT1, leading to NAD + depletion, an increased NADH/NAD + ratio, and ATF3 activation, which suppresses SLC7A11 and GPX4 expression and enhances tumor cell sensitivity to ferroptosis. In hepatocellular carcinoma cells, loss of TRAF2 promotes ROMO expression, increases the NADH/NAD + ratio, and accelerates cellular senescence. 3.2. Interaction between NADH/NAD + and immune microenvironment The NADH/NAD + ratio also plays an important role in the function of immune cells. Changes in the NADH/NAD + ratio can directly affect the activity and anti-tumor ability of T cells, CAR-T cells, macrophages, and other immune cells [ 15 , 66 , 67 ]. 3.2.1. NADH/NAD + interacts with T cells Changes in the NADH/NAD + ratio can enhance the anti-tumor activity of T cells by affecting their metabolic reprogramming and functional state. NAD + and NADH participate in both glycolysis and mitochondrial oxidative phosphorylation in T cells, helping T cells maintain energy supply in the nutrient-deficient tumor microenvironment, thereby avoiding functional exhaustion [ 15 , 67 ]. It has been found that T cells are able to actively uptake NAD + when exogenously supplemented, which leads to a decrease in the intracellular NADH/NAD + ratio and subsequent further activation of T cells. When the intracellular NAD + level is increased, it can enhance the killing effect of CAR T cells on tumor cells [ 66 ]. Tumor-infiltrating T cells located adjacent to the tumor often remain in a quiescent state. Studies have found that this is because these T cells reside in a microenvironment characterized by nutrient competition with tumor cells. As a result, they lack sufficient NAD + to sustain TCR signaling, leading to the inability to activate the transcription factor Tubby (TUB) in T cells. TUB acts as a transcription factor for NAMPT and is crucial for NAD + synthesis within T cells. Silencing of TUB will disrupt this biological axis of NAD + synthesis, causing a significant decrease in NAD + levels within the T cells, destabilizing the NADH/NAD + ratio, inhibiting mitochondrial ATP synthesis, and suppressing the downstream signals of the T cell receptor, ultimately leading to dysfunction of T cells in the tumor microenvironment [ 68 ]. Therefore, NAD + is an important factor for T cells and tumor cells to maintain their functions. When tumor cells acquire more NAD + than T cells, the function of T cells will be inhibited. 3.2.2. NADH/NAD + interacts with macrophages and NK cells Changes in the NADH/NAD + ratio also regulate the function of innate immune cells such as macrophages and natural killer (NK) cells. High levels of NAD + may promote the anti-tumor activity of M1 macrophages, while NAD + deficiency is associated with an immunosuppressive microenvironment. The high NADH/NAD + ratio promotes the polarization of M2 tumor-associated macrophages (TAM) and creates an immunosuppressive microenvironment [ 67 , 69 ]. In macrophages, CD40 self-activation will trigger fatty acid oxidation (FAO) and glutamine metabolism. Glutamine-derived glutamate is converted to lactate, which in turn reduces the NADH/NAD + ratio and further potentiates FAO-induced proinflammatory and antitumor activation [ 70 ]. Increased NAD + levels, that is, a decreased NADH/NAD + ratio, can enhance the cytotoxicity and cytokine secretion ability of NK cells by regulating cell metabolism and signaling pathways, such as the SIRT1-dependent pathways [ 71 , 72 ]. 3.2.3. NADH/NAD + is involved in immune escape NADH/NAD + also plays an important role in the escape of cancer cells from immune surveillance. Cancer cells can evade the recognition and clearance of the immune system by regulating NAD + metabolism, changing the tumor microenvironment, and inhibiting the function of immune cells. The metabolism of NAD + plays an important role in the regulation of immune checkpoints. Therefore, changes in the NADH/NAD + ratio in tumor cells can mediate the immune escape of tumor cells by regulating immune checkpoints. In various human malignant tumor cells, highly expressed NAMPT further promotes the expression of NAD + , leading to a decrease in the NADH/NAD + ratio. Studies have shown that NAD + can maintain the activity and expression of methylcytosine dioxygenase Tet1 through α-ketoglutarate (α-KG). IFNγ-activated Stat1 can further promote the binding of Tet1 to Irf1, regulating the demethylation of Irf1, thereby leading to upregulation of PD-L1 expression in tumor cells, enabling them to evade immune system attack. When NAMPT-mediated NAD + synthesis is enhanced, resulting in a decreased intracellular NADH/NAD + ratio, the activation and function of tumor-infiltrating CD8 + T cells are inhibited, thereby driving tumor immune escape [ 73 ]. Increased NAD + levels and the consequent reduction in the NADH/NAD + ratio can promote the nuclear translocation of PD-L1 by facilitating SIRT1-mediated deacetylation, thereby promoting tumor immune escape [ 74 ]. In tumor-infiltrating lymphocytes, NAD + is mainly sequestered by tumor cells, resulting in a reduced NADH/NAD + ratio within tumor cells. The resulting decrease in NAD + availability in lymphocytes inhibits the glycolysis pathway of lymphocytes, destroys the function of mitochondria, and then blocks the transduction of TCR cascade signal, damages the metabolism of TILs, and makes it lose its anti-tumor ability [ 75 ]. And the depletion of NAD + will affect the function of immune cells, such as T cells and macrophages, and weaken their anti-tumor ability [ 76 ]. In summary, the NADH/NAD + ratio can affect the anti-tumor activity of immune cells by dynamically regulating their metabolic reprogramming and functional state, including those of T cells, macrophages, and NK cells. Tumor cells can remodel the immunosuppressive microenvironment by altering NAD + metabolism, such as CD38-mediated NAD + depletion or SIRT1-PD-L1 axis, to evade immune surveillance. This bidirectional regulatory mechanism provides a new strategy for targeting NAD metabolism to enhance immunotherapy ( Fig. 6 ). Fig. 6. Open in a new tab Interaction between NADH/NAD + and the immune microenvironment. In the tumor immune microenvironment, changes in the NADH/NAD + ratio can influence T-cell and macrophage function, promote PD-L1 expression and nuclear translocation, and facilitate metabolic reprogramming. 3.3. Metabolic reprogramming drives the imbalance of NADH/NAD + ratio 3.3.1. Mitochondrial metabolism It has been suggested that metabolic reprogramming is a hallmark of malignancy. Metabolic reprogramming of tumor cells not only plays an important role in signal transduction to maintain tumorigenesis and survival, but also has a broad impact on the regulation of the anti-tumor immune response through the release of metabolites and the expression of immune molecules (such as lactate, PGE2, and arginine) [ 13 , 14 ]. In addition to its important function in normal cells, NADH/NAD + is also affected by metabolic reprogramming of tumor cells and has important implications for tumor progression. For example, alterations in mitochondrial metabolism in tumor cells affect the NADH/NAD + ratio and alter intracellular redox homeostasis. In gastric cancer cells, EIF2AK2 can upregulate the expression of OAS1, which increases the mitochondrial membrane potential, thereby promoting intracellular ATP production and down-regulating the NADH/NAD + ratio [ 17 ]. The elevated intracellular mitochondrial oxidative metabolism in glioblastomas leads to intracellular redox imbalance. This causes severe oxidative stress, which results in decreases in both NADH and NAD + levels and disrupts NADH/NAD + homeostasis [ 77 ]. In breast cancer cells, the transcription factor C/EBPβ-LIP can transfer NADH from cytoplasm to mitochondria through MAS, thereby promoting mitochondrial respiration and glycolysis. Under conditions of low glycolytic flux, C/EBPβ-LIP promotes the continuous conversion of NADH to NAD + in the cytoplasm and decreases the cytoplasmic NADH/NAD + ratio [ 78 ]. In renal cancer cells, when the supply of pyruvate is limited, HIF-1α can further suppress mitochondrial oxygen consumption, thereby leading to an increase in the NADH/NAD + ratio and a reduction in the lactate secretion of tumor cells [ 11 ]. Moreover, in mitochondria-driven metabolic reprogramming, blocking oxidative phosphorylation (OXPHOS) in the stem cell population or inhibiting mitochondrial fusion maintains tumor-initiating cells (TICs) in a quiescent state and the regeneration of NAD + is suppressed, which results in an increase in the NADH/NAD + ratio [ 79 ]. Enzymes in the mitochondria also play an important role in the regulation of the NADH/NAD + ratio. HES4 is a crucial regulator of mitochondrial electron transport chain activity and pyrimidine synthesis and is a negative regulator of NADH/NAD + ratio [ 16 ]. In pancreatic cancer, reduction of mitochondrial SIRT3 promotes the acetylation of glutamate oxaloacetate transaminase (GOT) in the mitochondria. This, in turn, facilitates the transfer of NADH into the mitochondria and reduces the ratio of NADH/NAD + in the cytoplasm [ 12 ]. Malate dehydrogenase degradation helper (MDHDH) binds to MDH2 (malate dehydrogenase 2) and promotes the interaction of ubiquitinated MDH2 with the proteasome, thereby enhancing MDH2 degradation. In turn, the membrane potential of mitochondria in tumor cells is altered, changing the balance of NADH/NAD + ratio [ 80 ]. 3.3.2. Glucose, lipid, amino acid metabolism In addition to mitochondrial metabolism, reprogramming of other cellular metabolic pathways also alters the intracellular homeostasis of NADH/NAD + . In patients with Succinate Dehydrogenase (SDH) deficiency, fatty acid (FA) metabolism will promote NADH oxidation, thereby reducing the NADH/NAD + ratio, which has an impact on tumor proliferation [ 81 ]. The peroxidation of phosphatidylcholine will inhibit the oxidation of NADH by complex I in the electron transport chain, increasing the NADH/NAD + ratio. This further leads to impairment of SIRT3 activity and induction of oxidative stress, thereby disrupting fatty acid β-oxidation [ 82 ]. In tumor cells, inhibiting the metabolism of glutamine can suppress the production of α-KG and NADH, and reduce the ratio of NADH/NAD + [ 83 ]. CircMYH9 promotes serine/glycine metabolism, reduces the ratio of NADH/NAD + , and regulates the redox homeostasis in tumor cells [ 84 ]. In the context of low folate (LF) in non-small-cell lung cancer cells, the cancer stem cell (CSC)-like phenotype of H23 cells leads to metabolic reprogramming of aerobic glycolysis. It promotes the release of lactic acid. This process inhibits the expression of pyruvate dehydrogenase E1-α, leads to pyruvate accumulation, reduces the NADH/NAD + ratio, and increases the oxidative state of the cells [ 85 ]. In hepatocellular carcinoma, transfection of the oncogene c-Myc leads to a decrease in the NADH/NAD + ratio through glucose metabolism [ 86 ]. Isocitrate dehydrogenase 2 (IDH2) reprograms glucose metabolism and bioenergy through the NF-κB signaling pathway in CRC. This process is accompanied by a significant increase in the NADH/NAD + ratio and can promote the progression of colorectal cancer [ 87 ]. In breast cancer cells, the transcription factor C/EBPβ-LIP can promote glycolysis and simultaneously facilitate the malate-aspartate shuttle (MAS). This enables the transfer of NADH from the cytoplasm to the mitochondria, resulting in a significant decrease in the ratio of NADH/NAD + [ 78 ]. Glutamate oxaloacetate transaminase 1 (GOT1) regulates cellular metabolism by coordinating the utilization of carbohydrates and amino acids. Studies have shown that in tumor cells with genetic mutations, inhibiting GOT1 disrupts cellular redox homeostasis and, under nutrient-deprived conditions, leads to a decrease in the NADH/NAD + ratio [ 88 ]. In tumor cells, lactate dehydrogenase-A (LDH-A) can catalyze the conversion of NADH to NAD + , maintaining glycolytic flux. Studies have shown that in tumor cells, by promoting the acetylation of P53 and inhibiting the activity of SIRT1, the expression of LDH-A can be suppressed, which will lead to an increase in the NADH/NAD + ratio in p53-dependent cancer cells [ 89 ]. The hydrogen transfer complex (HTC) is a complex composed of malate dehydrogenase 1, malatease 1, and cytosolic pyruvate carboxylase. It exists in the phase-separated bodies in the cytoplasm of cancer cells or hypoxic cells. It is capable of reprogramming metabolism and overcoming cellular senescence while reducing the intracellular NADH/NAD + ratio [ 90 ]. Therefore, the NADH/NAD + ratio is dynamically regulated in tumors by mitochondrial metabolism, key enzymes in vivo metabolism (such as HES4, SIRT3, LDH-A), oncogenic signals (HIF1-α, c-Myc), and glycolysis. Changes in this ratio can affect redox homeostasis, energy metabolism, and epigenetics, thereby affecting tumor progression ( Fig. 7 ). Fig. 7. Open in a new tab Metabolic reprogramming alters the NADH/NAD + ratio. In tumor cells, both mitochondrial and glycolytic reprogramming can lead to changes in the NADH/NAD + ratio. 4. Therapeutic strategies targeting the NADH/NAD + ratio 4.1. Targeting NADH or NAD + synthesis for tumor therapy NADH/NAD + plays a crucial role in regulating tumors, so targeting NADH/NAD + is an important therapeutic approach in cancer treatment. Currently, there are many studies that directly target or indirectly affect the synthesis of NADH and NAD + , which represent new strategies for tumor treatment. Resveratrol, as an antioxidant, plays an important role in triple-negative breast cancer. Studies have shown that in the presence of high concentrations of resveratrol, it can promote the expression of antioxidant-related genes SOD3 and FAM213B, as well as the reduction of NAD + to NADH, maintaining the redox microenvironment within the cells. This, in turn, inhibits cell growth through the MAPK signaling pathway, induces autophagy and apoptosis, inhibits the progression of cancer, and metformin can further enhance the therapeutic effect of high concentrations of resveratrol [ 91 ]. Under hypoxic conditions, HIF-1 can inhibit the activity of mitochondrial complex I through NDUFA4L2 (NADH dehydrogenase [ubiquinone] 1 alpha subcomplex subunit 4-like 2), promote the generation of NADH, reduce the production of mitochondrial reactive oxygen species (mitoROS), and promote the progression of lung squamous cell carcinoma. miR-183-5p can negatively regulate NDUFA4L2, inhibit the generation of NADH, induce the accumulation of mitoROS, and inhibit the progression of lung squamous cell carcinoma [ 92 ]. As an organic diselenide with redox activity in human lung cancer cells, 3,3′-diselenodipropionic acid (DSePA) exhibits time-dependent cytotoxicity. Within a short period, DSePA can increase the NADH/NAD + ratio, creating a reductive environment. However, after 48 h, it can induce oxidative stress that severely damages mitochondrial function and triggers cell apoptosis in a p53-independent manner [ 93 ]. In addition to regulating the synthesis of NADH, regulating the synthesis and consumption of NAD + and influencing the NADH/NAD + ratio are also promising therapeutic strategies for tumor treatment. Currently, more attention is paid to blocking the salvage synthesis pathway of NAD + and the Preiss–Handler pathway in tumors [ 94 ]. NAMPT inhibitors, including FK866/APO866 and CHS828/GMX1777, have been used in clinical trials and have shown significant anti-tumor effects in animal tumor models. However, their efficacy in clinical trials has not been particularly pronounced [ [95] , [96] , [97] ]. Therefore, it is urgent to find new inhibitors targeting NAMPT. A study has discovered a new NAMPT inhibitor, A4276, which can inhibit the generation of NAD + by NAMPT, causing NAPRT-negative EMT subtype cancer cells to die due to NAD + depletion. At the same time, it can also protect NAPRT-positive normal cells, as well as protect axons by reducing the ratio of MNM/NAD + [ 98 ]. Currently, the second-generation NAMPT inhibitors are classified into four categories: (i) NAMPT inhibitors following the classical pharmacophore model; (ii) NAMPT inhibitors with different structures; (iii) non-substrate type NAMPT inhibitors; (iv) dual-target inhibitors. Inhibitors based on the classical pharmacophore retain the canonical “head–linker unit–connecting chain–tail” architecture, but significantly improve metabolic stability, water solubility, and CYP450-related liabilities through structural optimization, such as water replacement and lactam incorporation, while preserving potent enzymatic inhibitory activity and enhancing druggability. Structurally distinct NAMPT inhibitors overcome the dose-limiting toxicities of first-generation inhibitors through novel binding modes or altered physicochemical properties, such as reduced retinal permeability. Non-substrate-type NAMPT inhibitors avoid the risk of CYP450 inhibition by preventing the formation of covalent adducts with PRPP, while maintaining in vivo antitumor efficacy. Dual-target inhibitors simultaneously suppress NAMPT and another key target, such as PAK4, NQO1, IDO1, EGFR, or HDAC, thereby synergistically blocking tumor metabolism and oncogenic signaling pathways and overcoming resistance to single-agent therapy [ 99 ]. The key enzymes targeting the Preiss–Handler pathway (NAPRT, NMNATs, NADSYN1) represent an important strategy for overcoming tumor resistance to NAMPT inhibitors. Since tumors often utilize nicotinic acid (NA) to maintain NAD + levels by activating this pathway, combined inhibition of NAMPT and NAPRT can exert a synthetic lethal effect, or in NAPRT-deficient tumors, NA supplementation can protect normal tissues. As NMNATs serve as the common node of all NAD + synthesis pathways, their inhibition is expected to completely block tumor NAD + production. In addition, the NADSYN1 inhibitor (e.g., compound 5284) has shown single-agent activity in tumor models dependent on the Preiss–Handler pathway [ 94 ]. In addition to the traditional approach of depleting NAD + to achieve tumor treatment through inhibition of its synthesis, regulating immunity or combining NAD + -targeted approaches with drugs is also a new direction for targeting NAD + in tumor treatment. The NAD + synthesis mediated by NAMPT can upregulate the activity of TET1 through α-ketoglutarate, thereby maintaining the PD-L1 expression induced by the IFNγ-STAT1-IRF1 signaling axis; tumors with high NAMPT expression are therefore more sensitive to anti-PD-(L)1 immunotherapy, and the combined use of NAD + supplements (such as NMN) can effectively sensitize tumors resistant to immunotherapy [ 73 ]. Further studies have found that NAMPT-mediated NAD + synthesis activates SIRT1, and SIRT1 can regulate the expression and nuclear localization of PD-L1. Targeting the NAMPT/SIRT1 metabolic axis can reverse immune therapy resistance and enhance efficacy [ 74 ]. LDH-A acts as a key enzyme that catalyzes the conversion of NADH to NAD + . By silencing LDH-A through RNAi or using the small molecule inhibitor NHI-2 to inhibit LDH-A, it can inhibit the production of NAD + and increase the NADH/NAD + ratio in a p53-dependent manner. At the same time, LDH-A inhibitors can act as potential therapeutic targets for cancer by synergizing with redox-dependent anti-cancer drugs [ 89 ]. Nanozyme-based catalysis is an emerging method for tumor therapy. In recent years, many studies have been carried out around the NADH oxidase NOX targeting NADH/NAD + to destroy the metabolism of tumors, and then affect the progression of tumors. For example, one group found that Ir N5SA can mimic NOX, the NADH oxidase, and thus disrupt the intracellular NADH/NAD + cycling balance. Moreover, it cooperates with the fatty acid synthetase cerulenin (Cer) to interfere with the energy metabolism homeostasis of tumor cells and inhibit the occurrence and development of tumors [ 20 ]. In summary, targeted regulation of NADH/NAD + synthesis can achieve precise interference with tumor metabolic homeostasis through various strategies such as directly regulating NADH production, blocking the NAD + salvage synthesis pathway (such as NAMPT inhibitors), interfering with key metabolic enzymes (such as LDH-A), and developing new nanoenzymes. 4.2. Regulation of NADH and NAD + shuttling inhibits tumor growth We have previously discussed that targeting the synthesis of NADH and NAD + is an important potential therapeutic approach for modulating the NADH/NAD + ratio. The shuttle of NADH and NAD + between the cytoplasm and mitochondria, as well as the functions mediated by changes in the NADH/NAD + ratio, may also play a significant role in the treatment of tumors. Some studies have shown that acetylation of glutamic oxaloacetate transaminase (GOT), a key enzyme in the malate-aspartate shuttle, can promote the transfer of NADH into mitochondria, resulting in an increased NADH/NAD + ratio in mitochondria, thereby promoting ATP production [ 12 ]. At this point, targeting the key enzymes in the NADH/NAD + shuttle system offers a promising therapeutic strategy. By modulating the NADH/NAD + ratio, this approach can suppress mitochondrial ATP production in tumor cells and subsequently inhibit tumor progression, highlighting its significant potential for cancer treatment. In triple-negative breast cancer cells, C/EBPβ-LIP accelerates the conversion of cytoplasmic NADH to NAD + through activating the malate-aspartate shuttle (MAS), making the cells extremely sensitive to glycolysis inhibitors (2-DG); when glycolysis is inhibited, the continuous MAS activity depletes NADH, causing an excessively low NADH/NAD + ratio and inducing apoptosis through the mitochondrial pathway. This indicates that combined glycolysis inhibition and modulation of NADH/NAD + metabolism may represent a potential therapeutic strategy for triple-negative breast cancer [ 78 ]. Using the malate-aspartate inhibitor AOA, it was found that the steady state of the NADH/NAD + ratio was disrupted. This could inhibit the lactate dehydrogenase activity in the mitochondria of cancer cells, thereby inhibiting the oxidation of l -lactic acid and reducing the energy supply to cancer cells [ 100 ]. Malate dehydrogenase 1 is a key component of the malate-aspartate shuttle. A potential inhibitor, BI-2536, was identified to inhibit MDH1 activity and block the growth of lung adenocarcinoma cells [ 101 ]. A sonogenically activated malate-depletion modulator, GO/BCT:Mn, can inhibit malate synthesis and disrupt the malate/aspartate shuttle. This will alter the NADH/NAD + equilibrium, damage the integrity of mitochondria, and thereby significantly inhibit the progression of cancer [ 102 ] Therefore, targeting the malate-aspartate shuttle can disrupt the NADH/NAD + equilibrium, inhibit tumor energy metabolism, and when combined with glycolysis inhibitors, it becomes a potential target for tumor treatment. 4.3. Tumor microenvironment remodeling regulates NADH/NAD + to achieve tumor therapy In addition to directly acting on the synthesis of NADH and NAD + and altering the ratio of NADH/NAD + by regulating its shuttling and function, remodeling the tumor metabolic microenvironment can also regulate the ratio of NADH/NAD + . In neuroblastoma, using the inhibitor SR13800 to inhibit the lactate transporter monocarboxylate transporter 1 (MCT1) will increase the intracellular lactate level. When the MCT1 inhibitor SR13800 is combined with the LDH-A inhibitor FX11, it causes a marked accumulation of pyruvate in cancer cells. These metabolic changes will disrupt the balance of the NADH/NAD + ratio and significantly inhibit the viability of neuroblastoma cells [ 103 ]. In renal cells with VHL deficiency, one characteristic phenotype is the reductive stress caused by an excessively high NADH/NAD + ratio. By removing glucose or supplementing with electron acceptors such as pyruvate or resazurin, the intracellular NADH/NAD + ratio can be reduced, alleviating the reductive stress resulting from the excessively high ratio. This enables the restoration of mitochondrial respiration and tricarboxylic acid cycle activity, providing a potential metabolic regulatory strategy for the treatment of VHL-deficient renal cancer [ 104 ]. In cancer cells without genetic defects, exogenous supplementation of pyruvate and dichloroacetate (DCA) can reduce the lactate/pyruvate ratio in the tumor microenvironment. This simultaneously lowers the NADH/NAD + ratio, thereby enhancing JNK-Bax-mediated mitochondrial apoptosis and increasing the sensitivity of tumor cells to chemotherapeutic drugs that induce oxidative stress [ 10 ]. Further studies have shown that in liver cancer cells; after being exposed to trichostatin A (TSA), TSA can inhibit histone acetylation. This enables the restoration of the function of alcohol dehydrogenase 4 (ADH4) that was inhibited by c-Myc, thereby reducing the expression levels of p-AKT and p-mTOR, decreasing ATP production, and consequently lowering the overall content of NADH and NAD + . This inhibits the progression of liver cancer cells [ 86 ]. By genetically knocking out the FAMIN gene in mice, it was found that inhibiting the purine nucleoside enzyme FAMIN can lead to cytoplasmic NADH/NAD + reduction stress by disrupting the adenine-guanine nucleotide cycle. This results in enhanced tumor-killing effect mediated by T cells and also strengthens the immune surveillance of tumors [ 105 ]. Consequently, targeting FAMIN to regulate the NADH/NAD + ratio can serve a dual function: it facilitates tumor monitoring by modulating FAMIN's activity and suppresses tumor progression by enhancing autoimmune responses. As an important drug for treating gastric cancer, oxaliplatin can inhibit the NADH oxidase tNOX (tumor-associated NADH oxidase (tNOX)). This causes an increase in the ratio of NADH/NAD + within the cells and inhibits the activity of NAD + -dependent deacetylase SIRT1, thereby enhancing the acetylation of P53 and promoting cell apoptosis [ 19 ]. Under mild hypoxia, some tumor stem cells exhibit a highly proliferative state. However, when severe hypoxia occurs, the ratio of NADH/NAD + within tumor cells will increase. When this increase exceeds a certain threshold, the high NADH will inhibit the activity of GAPDH and slow down glycolysis. The high NADH/NAD + ratio will directly lead to a decrease in the relative cell proliferation rate, and high concentrations of NADH will cause the accumulation of TP53, disrupting the balance between proliferation and apoptosis and initiating the apoptosis program [ 11 , 106 ]. Another group created A nanoenzyme-based NADH-cycling oxidation nanoreactor (Co-HCS/D/A) to disrupt tumor metabolism through triple cellular metabolism. It can simultaneously disrupt the oxidative phosphorylation (OXPHOS), NADH-cycling oxidation, glycolysis and pentose phosphate pathways of tumor cells, which largely overcomes the limitations of regulating tumor metabolism based on nanozymes [ 107 ]. Accordingly, it can be observed that by interfering with lactate metabolism, supplementing electron receptors, or regulating metabolic products in the microenvironment, it is possible to effectively restore the NADH/NAD + homeostasis in tumors, providing new strategies for resolving metabolic adaptation and enhancing treatment sensitivity ( Table 1 ). Table 1. Therapeutic strategies targeting the NADH/NAD + ratio. Type Intervention method Mechanism Effect References Targeted synthesis of NADH or NAD + for tumor therapy High-concentration resveratrol High concentrations of resveratrol promote the expression of SOD3 and FAM213B, and also facilitate the reduction of NAD + to NADH, thereby activating the AMPK pathway.thereby activating the AMPK pathway. Inhibit the growth of tumor cells and induce autophagy and apoptosis of tumor cells 10.1016/j.freeradbiomed.2022.01.010 . DSePA DSePA increases the NADH/NAD + ratio, induces oxidative stress, and damages the mitochondria of tumor cells. Inducing apoptosis of tumor cells 10.1016/j.freeradbiomed.2021.08.017 . Inhibitor A4276 A4276 inhibits NAMPT, thereby inhibiting NAD + production and promoting NAD + depletion. Inducing the death of tumor cells 10.7150/thno.85356 . MNM combined with immunotherapy Supplementation with NMN can increase the content of NAD + , induce the expression of PD-L1, and make tumor cells more sensitive to anti-PD-L1 therapy. Enhance the efficacy of immunotherapy 10.1002/advs.202412109 . Inhibitor NHI-2 NHI-2 inhibits LDH-A and inhibits the generation of NADH Enhance the efficacy of anti-tumor drugs 10.1038/oncsis.2014.16 . Regulating the shuttle of NADH or NAD + for the treatment of tumors Inhibitor AOA AOA disrupts the NADH/NAD + balance, inhibits the activity of lactate dehydrogenase, and thereby inhibits the oxidation of l-lactic acid Reduce the supply of energy to tumor cells 10.1002/jcp.29160 . Inhibitor BI-2536 BI-2536 inhibits the activity of MDH1 Inhibit the proliferation of tumor cells 10.3389/fimmu.2025.1631449 . GO/BCT:Mn GO/BCT: Mn inhibits the synthesis of malate and disrupts the malate/aspartate shuttle. Damage to mitochondrial integrity 10.1016/j.bioactmat.2025.10.028 . Regulating the tumor microenvironment and targeting NADH/NAD + for tumor treatment SR13800 combined with FX1 The combined use of SR13800 and FX11 can inhibit MCT1 and promote the accumulation of lactate and pyruvate. Inhibit the activity of neuroblastoma 10.1038/s41388-020-1235-2 . Oxaliplatin Inhibit NADH oxidase tNOX, increase the NADH/NAD + ratio, inhibit SIRT1 activity, and thereby enhance P53 acetylation Promote cell apoptosis 10.18632/oncotarget.14787 . Oxygen deficiency Hypoxia leads to an increase in NADH content, inhibits GAPDH, slows down glycolysis, and causes the accumulation of P53. Inhibit the proliferation of tumor cells and promote their apoptosis. 10.1038/s41540-024-00377-x . Co-HCS/D/A Co-HCS/D/A disrupts the oxidative phosphorylation, NADH cycle, glycolysis and pentose phosphate pathway in tumor cells. Disrupt the metabolic processes of tumor cells 10.1002/smll.202311027 . TSA The TSA reduces the expression levels of P-AKT and P-mTOR, decreases ATP production, and consequently lowers the contents of NADH and NAD + . Inhibit the progression of cancer 10.1186/s12885-024-12781-x . Open in a new tab 5. Challenge and outlook 5.1. Basic research: NADH/NAD + balance is a dual regulator of in situ and metastatic tumors 5.1.1. The role of NADH/NAD + in in situ tumors As a common molecule in body metabolism, NADH/NAD + plays an important role in the maintenance of mitochondrial function, metabolic remodeling, cell fate, and redox balance [ 40 , 108 ]. In recent years, with the deepening of research on tumors, it has been discovered that changes in the NADH/NAD + ratio have an impact on the progression of tumors. When the NADH/NAD + ratio decreases, it can promote the progression of tumors. However, when the NADH/NAD + ratio is excessively elevated, it can disrupt the mitochondrial respiratory chain and lead to oxidative stress, thereby inhibiting the progression of tumor [ 11 , 12 , 54 , 58 ]. Therefore, future research should focus on elucidating the precise regulatory network governing the dynamic changes in the NADH/NAD + ratio. Additionally, efforts should be made to explore the utilization of its dual effects (tumor-promoting at low levels and tumor-suppressive at high levels) to design novel metabolic intervention therapies. Further investigation into the underlying regulatory mechanisms has shown that changes can also be related to NADH/NAD + [ 12 , 17 , 78 ]. In the future, it is necessary to focus on the specific changes of NADH/NAD + at the organelle level and further elucidate its role in tumor oxidative stress. NADH/NAD + also plays an important role in tumor immunity, as it can regulate immune-cell activity, reshape the tumor immune microenvironment, and contribute to immune escape [ 68 , 73 ]. The activation of immune cells is also highly dependent on NAD + . Therefore, in the future, efforts should be focused on inhibiting NAD + within tumor cells while maintaining the normal function of immune cells. Identifying the most appropriate combination therapy strategy will become an important research direction in tumor immunometabolism. 5.1.2. The role of NADH/NAD + in metastatic tumors In addition to its role in orthotopic tumor, NADH/NAD + also plays a key role in the process of tumor cells achieving distant metastasis. It has been found that the decreased expression of DNA methyltransferase DNMT promotes the conversion of glutamate to γ-aminobutyric acid by glutamic acid decarboxylase 1 (GAD1) in the tumor microenvironment of brain metastases. This would promote glutamine-driven energy metabolism, reduce the NADH/NAD + ratio, and promote the growth of brain metastatic tumors [ 109 ]. Low folate induction enhances the CSC-like properties of NSCLC cells, reduces the NADH/NAD + ratio through metabolic reprogramming, and promotes lung cancer cell metastasis [ 85 ]. Current studies mostly focus on changes in the NADH/NAD + ratio at the global cellular or tissue level. However, NAD + pools in the mitochondria, nucleus, and cytoplasm are relatively independent and functionally specialized. Future studies could focus on the changes in NADH/NAD + ratio at the cellular organelle level. In particular, changes in the NADH/NAD + ratio in aggressive tumors and in the microenvironment of tumor metastases will help to understand precisely how the NADH/NAD + ratio locally modulates metastasis. At the same time, the interactive regulatory network between metabolic reprogramming and epigenetic modification also needs to be paid attention. DNA methyltransferases can affect the NADH/NAD + ratio by regulating the microenvironment of tumor metastasis. However, whether alterations in the NADH/NAD + ratio within the metastatic tumor microenvironment can regulate the activity of DNA methyltransferases or histone-modifying enzymes through NAD + -dependent sensors, such as members of the sirtuin family or PARP, and thereby influence tumor progression, remains to be further investigated. 5.2. Clinical translation: develop NADH/NAD + -based strategies for cancer diagnosis and treatment 5.2.1. Tumor diagnosis based on NADH/NAD + The homeostasis of NADH/NAD + ratio is essential for maintaining cellular activities, and disruption of its ratio in tumors affects tumor progression. A highly sensitive and specific fluorescent probe, BQ, has been developed to monitor mitochondrial NADH. Real-time visualization of the REDOX dynamics of living cells and in vivo has been achieved, which can assess oxidative stress and distinguish cancer cells from normal cells [ 110 ]. Label-free metabolic intravital imaging (LMII) has also been used to detect NADH-stimulated autofluorescence signals in triple-negative breast cancer (TNBC), enabling monitoring of metabolic responses to immunotherapy. This enables the visualization of dynamic changes in the metabolism of cancer cells and immune infiltration in heterogeneous cells under immunotherapy, achieving sensitive and comprehensive monitoring [ 111 ]. However, the delivery of probes into deep tumor tissue is a major challenge, and it is difficult to achieve high-resolution imaging of deep tissues with autofluorescent probes. Future studies should incorporate ultrasound-guided techniques to break through the limitations of tissue penetration depth and achieve high-resolution imaging of deep tumors. At the same time, NADH fluorescence imaging was fused with traditional imaging technology to develop a multimodal molecular imaging system that enables comprehensive assessment of molecular metabolic changes and anatomical abnormalities, thereby improving the accuracy and interpretability of tumor diagnosis. 5.2.2. Targeting NADH/NAD + to achieve tumor therapy By targeting NADH/NAD + at the source, influencing the shuttle of NADH and NAD + , as well as altering the tumor metabolic microenvironment, it is possible to change the NADH/NAD + ratio and affect the progression of the tumor [ 78 , 91 , 94 , 103 ]. This multi-dimensional intervention strategy is worthy of further exploration. The combined inhibition of NAD + synthesis and its transport within mitochondria may be able to exert a synergistic effect. For example: when a NAMPT inhibitor inhibits the synthesis of NAD + in the cytoplasm, and simultaneously blocks the malate-aspartate shuttle in mitochondria, it can cut off the ATP synthesis of the tumor while disrupting the tumor's reduction system, inducing a synthetic lethal effect. The remodeling of the tumor metabolic microenvironment can also provide new ideas for drug resistance treatment. By regulating the accumulation of lactic acid and the metabolism of some substances in the tumor microenvironment, and indirectly changing the NADH/NAD + ratio of tumor cells, it may increase the sensitivity of immune checkpoint inhibitors or chemotherapy drugs. However, how to select the best intervention method based on different tumor subtypes is the core issue for future clinical translation. In summary, NADH/NAD + has gone beyond the scope of traditional metabolic coenzymes and has become a central molecule connecting the three core networks of energy metabolism - redox - immune response. The multi-dimensional intervention strategy targeting its metabolism has shown broad translational prospects. 6. Summary NADH/NAD + is involved in the maintenance of normal physiological functions of the body. The imbalance of its ratio plays an important role in the occurrence and development of tumors. A decrease in the NADH/NAD + ratio can promote tumor progression, whereas an increase can inhibit tumor progression. The change of NADH/NAD + ratio also affects the tumor immune microenvironment. The ratio of NADH/NAD + is also regulated by metabolic reprogramming of tumors. Targeting NADH or NAD + synthesis at the source, affecting NADH/NAD + shuttle, or regulating the microenvironment to alter NADH/NAD + have great potential in cancer therapy. In the future, research should focus on the effects of organelle-specific changes in NADH/NAD + on tumor biology, as well as on the clinical translation of therapies targeting NADH/NAD + in cancer. Funding This work was supported by the National Key Research and Development Plan (2022YFC3401000), National Natural Science Foundation of China (92359302), Guangdong Science and Technology Planning Program (2021B1212040017), National Natural Science Foundation of China (82472087), Natural Science Foundation of Fujian Province (2024J011004), Fujian Provincial Health and Medical High-Level Talent Team (XM050005), Guangdong Basic and Applied Basic Research Foundation (2021B1515230009), Guangdong Provincial Key Areas R&D Programs of “Precision medicine and stem cells” (2023B1111020005), the Natural Science Foundation for Outstanding Youth Team Project of Guangdong Province (2024B1515040030), Ganzhou Municipal Science and Technology Project (2022-RC1342), National Natural Science Foundation of China (82500759), Postdoctoral Fellowship Program of CPSF (GZB20240394, 2025M772140), Xiamen Health High Quality Development Project (2024GZL-GG06), Foundation for Cultivated Young Talents of Fujian Province, China (2025350237), Fujian Provincial Health and Technology Program - Young and Middle-aged Key Talent Development Project (2025GGA095), Young Investigator Research Program of Xiang'an Hospital of Xiamen University (XAH24007). CRediT authorship contribution statement Jing Li: Visualization, Writing – original draft. Tong Zhang: Visualization, Writing – original draft. Tianrong Ma: Writing – original draft. Tao Chen: Funding acquisition, Supervision, Writing – review & editing. Xianzhi Liu: Funding acquisition, Writing – original draft, Writing – review & editing. Weiling He: Funding acquisition, Supervision, Writing – review & editing. Declaration of competing interest The authors declare no competing interests. Acknowledgments We thank all members of the Weiling He’ team for their support and technical assistance. The figures in this review were created and authorized by Biorender. Contributor Information Tao Chen, Email: [email protected]. Xianzhi Liu, Email: [email protected]. Weiling He, Email: [email protected]. Abbreviations NADH, nicotinamide adenine dinucleotide; NAD + oxidized nicotinamide adenine dinucleotide; TCA, tricarboxylic acid; CtBPs, C-terminal binding proteins; ETC, electron transport chain; PHGDH, phosphoglycerate dehydrogenase; α-KG, α-ketoglutarate; 2-HG, 2-hydroxyglutarate; PDH, pyruvate dehydrogenase complex; NRF2, nuclear respiratory factor 2; SIRTs, sirtuin family of deacetylases; GCKR, glucokinase regulator; OXPHOX, oxidative phosphorylation; MID, myocardial iron deficiency; PARP1, poly-ADP-ribose-polymerases1; SHMT2, serine hydroxymethyltransferase 2; ROS, reactive oxygen species; ΔΨ, mitochondrial membrane potential; PBEC, purine biosynthesis-driven energy crisis; LDH, lactate dehydrogenase; GOT, glutamate oxaloacetate transaminases; TICs, tumor-initiating cells; SDH, Succinate Dehydrogenase; FA, atty acid; LF, Low-folate; CSC, cancer stem cell; HCC, hepatocellular carcinoma; IDH2, isocitrate dehydrogenase 2; C/EBPβ, CCAAT/enhancer binding protein beta; MAS, malate-aspartate shuttle; HIF1α, Hypoxia-inducible factor-1α; GAPDH, glyceraldehyde 3-phosphate dehydrogenase; OCR, oxygen consumption; DLD, Dihydrolipoamide dehydrogenase; MDHDH, malate dehydrogenase degradation helper; MDH2, malate dehydrogenase 2; NFIB, Nuclear factor IB; NAMPT, NAD + recovery rate-limiting enzyme; PP2A, protein phosphatase 2A; CIP2A, cancerous inhibitor of protein phosphatase 2A; HTC, Hydride transfer complex; EIF2AK2, Eukaryotic translation initiation factor 2α kinase 2; p-AKT, phosphorylated protein kinase B; TSA, Trichostatin A; DSePA., 3,3′-diselenodipropionic acid; OCCC, Ovarian clear cell carcinoma; MTOB, 4-methylthio-2-oxobutyric acid; EVs, Extracellular vesicles; MPM, micropeptide in mitochondria; HIF-1, Hypoxia-inducible factor-1; NDUFA4L2, NADH dehydrogenase 1 alpha subunit complex subunit 4-like 2; mitoROS, mitochondrial reactive oxygen species; MCT1, monocarboxylate transporter 1; Mir-26b, microRNAs miR-26b; CD, Citrin deficiency; RCS, renal cancer syndromes; VHL, von Hippel-Lindau; Tnox, tumor-associated NADH oxidase; TRAF2, Tumor necrosis factor receptor-associated factor 2; ROMO1, reactive oxygen species modulator 1. Data availability No data was used for the research described in the article. References 1. Weiss-Sadan T., Ge M., Hayashi M., et al. NRF2 activation induces NADH-Reductive stress, providing a metabolic vulnerability in lung cancer. Cell Metab. 2023;35(3):487–503.e7. doi: 10.1016/j.cmet.2023.01.012. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Lu M.J., Busquets J., Impedovo V., et al. SLC25A51 decouples the mitochondrial NAD(+)/NADH ratio to control proliferation of AML cells. Cell Metab. 2024;36(4):808–821.e6. doi: 10.1016/j.cmet.2024.01.013. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Walker M.A., Tian R. NAD metabolism and heart failure: mechanisms and therapeutic potentials. J. Mol. Cell. Cardiol. 2024;195:45–54. doi: 10.1016/j.yjmcc.2024.07.008. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Wang Y., Stancliffe E., Fowle-Grider R., et al. Saturation of the mitochondrial NADH shuttles drives aerobic glycolysis in proliferating cells. Mol. Cell. 2022;82(17):3270–3283.e9. doi: 10.1016/j.molcel.2022.07.007. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Yan L.J. NADH/NAD(+) redox imbalance and diabetic kidney disease. Biomolecules. 2021;11(5) doi: 10.3390/biom11050730. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 6. Black H.S. A synopsis of the associations of oxidative stress, ROS, and antioxidants with diabetes mellitus. Antioxidants. 2022;11(10) doi: 10.3390/antiox11102003. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Baixauli F., Piletic K., Puleston D.J., et al. An LKB1-mitochondria axis controls T(H)17 effector function. Nature. 2022;610(7932):555–561. doi: 10.1038/s41586-022-05264-1. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 8. Sharma R., Reinstadler B., Engelstad K., et al. Circulating markers of NADH-reductive stress correlate with mitochondrial disease severity. J. Clin. Investig. 2021;131(2) doi: 10.1172/JCI136055. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 9. Alonso-Lavin A.J., Bajić D., Poyatos J.F. Tolerance to NADH/NAD(+) imbalance anticipates aging and anti-aging interventions. iScience. 2021;24(7) doi: 10.1016/j.isci.2021.102697. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 10. Go S., Kramer T.T., Verhoeven A.J., et al. The extracellular lactate-to-pyruvate ratio modulates the sensitivity to oxidative stress-induced apoptosis via the cytosolic NADH/NAD(+) redox state. Apoptosis. 2021;26(1-2):38–51. doi: 10.1007/s10495-020-01648-8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 11. Urrutia A.A., Mesa-Ciller C., Guajardo-Grence A., et al. HIF1α-dependent uncoupling of glycolysis suppresses tumor cell proliferation. Cell Rep. 2024;43(4) doi: 10.1016/j.celrep.2024.114103. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 12. Yang H., Zhou L., Shi Q., et al. SIRT3-dependent GOT2 acetylation status affects the malate-aspartate NADH shuttle activity and pancreatic tumor growth. EMBO J. 2015;34(8):1110–1125. doi: 10.15252/embj.201591041. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 13. Xia L., Oyang L., Lin J., et al. The cancer metabolic reprogramming and immune response. Mol. Cancer. 2021;20(1):28. doi: 10.1186/s12943-021-01316-8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 14. Faubert B., Solmonson A., Deberardinis R.J. Metabolic reprogramming and cancer progression. Science. 2020;368(6487) doi: 10.1126/science.aaw5473. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 15. Navas L.E., Carnero A. NAD(+) metabolism, stemness, the immune response, and cancer. Signal Transduct. Targeted Ther. 2021;6(1):2. doi: 10.1038/s41392-020-00354-w. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 16. He J., Wang A., Zhao Q., et al. RNAi screens identify HES4 as a regulator of redox balance supporting pyrimidine synthesis and tumor growth. Nat. Struct. Mol. Biol. 2024;31(9):1413–1425. doi: 10.1038/s41594-024-01309-3. [ DOI ] [ PubMed ] [ Google Scholar ] 17. Lai Y., Wang X., Ma J., et al. Knockdown of EIF2AK2-OAS1 axis reduces ATP production inducing AMPK phosphorylation to inhibit the malignant behavior of gastric cancer cells. J. Bioenerg. Biomembr. 2024;56(4):433–449. doi: 10.1007/s10863-024-10023-0. [ DOI ] [ PubMed ] [ Google Scholar ] 18. Birts C.N., Banerjee A., Darley M., et al. p53 is regulated by aerobic glycolysis in cancer cells by the CtBP family of NADH-dependent transcriptional regulators. Sci. Signal. 2020;13(630) doi: 10.1126/scisignal.aau9529. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 19. Chen H.Y., Cheng H.L., Lee Y.H., et al. Tumor-associated NADH oxidase (tNOX)-NAD+-sirtuin 1 axis contributes to oxaliplatin-induced apoptosis of gastric cancer cells. Oncotarget. 2017;8(9):15338–15348. doi: 10.18632/oncotarget.14787. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 20. Liu Y., Wang B., Zhu J., et al. Single-atom nanozyme with asymmetric electron distribution for tumor catalytic therapy by disrupting tumor redox and energy metabolism homeostasis. Adv. Mater. 2023;35(9) doi: 10.1002/adma.202208512. [ DOI ] [ PubMed ] [ Google Scholar ] 21. Ying W. NAD+/NADH and NADP+/NADPH in cellular functions and cell death: regulation and biological consequences. Antioxidants Redox Signal. 2008;10(2):179–206. doi: 10.1089/ars.2007.1672. [ DOI ] [ PubMed ] [ Google Scholar ] 22. Castro-Portuguez R., Sutphin G.L. Kynurenine pathway, NAD(+) synthesis, and mitochondrial function: targeting tryptophan metabolism to promote longevity and healthspan. Exp. Gerontol. 2020;132 doi: 10.1016/j.exger.2020.110841. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 23. Curran C.S., Kopp J.B. The complexity of nicotinamide adenine dinucleotide (NAD), hypoxic, and aryl hydrocarbon receptor cell signaling in chronic kidney disease. J. Transl. Med. 2023;21(1):706. doi: 10.1186/s12967-023-04584-8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 24. Koju N., Qin Z.H., Sheng R. Reduced nicotinamide adenine dinucleotide phosphate in redox balance and diseases: a friend or foe? Acta Pharmacol. Sin. 2022;43(8):1889–1904. doi: 10.1038/s41401-021-00838-7. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 25. Imai S., Yoshino J. The importance of NAMPT/NAD/SIRT1 in the systemic regulation of metabolism and ageing. Diabetes Obes. Metabol. 2013;15(Suppl 3):26–33. doi: 10.1111/dom.12171. 0 3. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 26. Yoshino J., Baur J.A., Imai S.I. NAD(+) intermediates: the biology and therapeutic potential of NMN and NR. Cell Metab. 2018;27(3):513–528. doi: 10.1016/j.cmet.2017.11.002. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 27. Bogan K.L., Brenner C. Nicotinic acid, nicotinamide, and nicotinamide riboside: a molecular evaluation of NAD+ precursor vitamins in human nutrition. Annu. Rev. Nutr. 2008;28:115–130. doi: 10.1146/annurev.nutr.28.061807.155443. [ DOI ] [ PubMed ] [ Google Scholar ] 28. Tempel W., Rabeh W.M., Bogan K.L., et al. Nicotinamide riboside kinase structures reveal new pathways to NAD+ PLoS Biol. 2007;5(10) doi: 10.1371/journal.pbio.0050263. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 29. Karpe F., Frayn K.N. The nicotinic acid receptor--a new mechanism for an old drug. Lancet. 2004;363(9424):1892–1894. doi: 10.1016/S0140-6736(04)16359-9. [ DOI ] [ PubMed ] [ Google Scholar ] 30. Badawy A.A. Kynurenine pathway of tryptophan metabolism: regulatory and functional aspects. Int. J. Tryptophan Res. 2017;10 doi: 10.1177/1178646917691938. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 31. Xue C., Li G., Zheng Q., et al. Tryptophan metabolism in health and disease. Cell Metab. 2023;35(8):1304–1326. doi: 10.1016/j.cmet.2023.06.004. [ DOI ] [ PubMed ] [ Google Scholar ] 32. Chandel N.S. Glycolysis. Cold Spring Harbor Perspect. Biol. 2021;13(5) doi: 10.1101/cshperspect.a040535. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 33. Maclean A., Legendre F., Appanna V.D. The tricarboxylic acid (TCA) cycle: a malleable metabolic network to counter cellular stress. Crit. Rev. Biochem. Mol. Biol. 2023;58(1):81–97. doi: 10.1080/10409238.2023.2201945. [ DOI ] [ PubMed ] [ Google Scholar ] 34. Zhu Y., Liu J., Park J., et al. Subcellular compartmentalization of NAD(+) and its role in cancer: a sereNADe of metabolic melodies. Pharmacol. Ther. 2019;200:27–41. doi: 10.1016/j.pharmthera.2019.04.002. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 35. Xiao W., Loscalzo J. Metabolic responses to reductive stress. Antioxidants Redox Signal. 2020;32(18):1330–1347. doi: 10.1089/ars.2019.7803. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 36. Lehninger A.L., Wadkins C.L., Cooper C., et al. Oxidative phosphorylation. Science. 1958;128(3322):450–456. doi: 10.1126/science.128.3322.450. [ DOI ] [ PubMed ] [ Google Scholar ] 37. Drekolia M.K., Karantanou C., Wittig I., et al. Loss of cardiac mitochondrial complex I persulfidation impairs NAD(+) homeostasis in aging. Redox Biol. 2024;69 doi: 10.1016/j.redox.2023.103014. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 38. Liu S., Fu S., Wang G., et al. Glycerol-3-phosphate biosynthesis regenerates cytosolic NAD(+) to alleviate mitochondrial disease. Cell Metab. 2021;33(10):1974–1987.e9. doi: 10.1016/j.cmet.2021.06.013. [ DOI ] [ PubMed ] [ Google Scholar ] 39. Schwartz B., Gjini P., Gopal D.M., et al. Inefficient batteries in heart failure: metabolic bottlenecks disrupting the mitochondrial ecosystem. JACC, Basic Transl. Sci. 2022;7(11):1161–1179. doi: 10.1016/j.jacbts.2022.03.017. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 40. Tannous C., Booz G.W., Altara R., et al. Nicotinamide adenine dinucleotide: biosynthesis, consumption and therapeutic role in cardiac diseases. Acta Physiol. 2021;231(3) doi: 10.1111/apha.13551. [ DOI ] [ PubMed ] [ Google Scholar ] 41. Pan X., Heacock M.L., Abdulaziz E.N., et al. A genetically encoded tool to increase cellular NADH/NAD(+) ratio in living cells. Nat. Chem. Biol. 2024;20(5):594–604. doi: 10.1038/s41589-023-01460-w. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 42. Chang J.C., Go S., Gilglioni E.H., et al. Soluble adenylyl cyclase regulates the cytosolic NADH/NAD(+) redox state and the bioenergetic switch between glycolysis and oxidative phosphorylation. Biochim. Biophys. Acta Bioenerg. 2021;1862(4) doi: 10.1016/j.bbabio.2020.148367. [ DOI ] [ PubMed ] [ Google Scholar ] 43. Gomes A.P., Price N.L., Ling A.J., et al. Declining NAD(+) induces a pseudohypoxic state disrupting nuclear-mitochondrial communication during aging. Cell. 2013;155(7):1624–1638. doi: 10.1016/j.cell.2013.11.037. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 44. Jaiswal A., Singh R. CtBP: a global regulator of balancing acts and homeostases. Biochim. Biophys. Acta Rev. Canc. 2023;1878(3) doi: 10.1016/j.bbcan.2023.188886. [ DOI ] [ PubMed ] [ Google Scholar ] 45. Singh C., Jin B., Shrestha N., et al. ChREBP is activated by reductive stress and mediates GCKR-associated metabolic traits. Cell Metab. 2024;36(1):144–158.e7. doi: 10.1016/j.cmet.2023.11.010. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 46. Lu Y., George J. Interaction between fatty acid oxidation and ethanol metabolism in liver. Am. J. Physiol. Gastrointest. Liver Physiol. 2024;326(5):G483–g494. doi: 10.1152/ajpgi.00281.2023. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 47. Luo M., Ma X., Ye J. Reductive stress-a common metabolic feature of obesity and cancer. Acta Pharm. Sin. B. 2024;14(12):5181–5185. doi: 10.1016/j.apsb.2024.08.034. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 48. Liiv M., Vaarmann A., Safiulina D., et al. ER calcium depletion as a key driver for impaired ER-to-mitochondria calcium transfer and mitochondrial dysfunction in Wolfram syndrome. Nat. Commun. 2024;15(1):6143. doi: 10.1038/s41467-024-50502-x. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 49. Luengo A., Li Z., Gui D.Y., et al. Increased demand for NAD(+) relative to ATP drives aerobic glycolysis. Mol. Cell. 2021;81(4):691–707.e6. doi: 10.1016/j.molcel.2020.12.012. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 50. Zhang Y., Liu Z., Wang X., et al. SHMT2 promotes cell viability and inhibits ROS-dependent, mitochondrial-mediated apoptosis via the intrinsic signaling pathway in bladder cancer cells. Cancer Gene Ther. 2022;29(10):1514–1527. doi: 10.1038/s41417-022-00470-5. [ DOI ] [ PubMed ] [ Google Scholar ] 51. Léopold V., Chouchane O., Butler J.M., et al. Platelets of COVID-19 patients display mitochondrial dysfunction, oxidative stress, and energy metabolism failure compatible with cell death. Res Pract Thromb Haemost. 2023;7(7) doi: 10.1016/j.rpth.2023.102213. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 52. Yang R., Yang C., Ma L., et al. Identification of purine biosynthesis as an NADH-sensing pathway to mediate energy stress. Nat. Commun. 2022;13(1):7031. doi: 10.1038/s41467-022-34850-0. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 53. Corradi F., Masini G., Bucciarelli T., et al. Iron deficiency in myocardial ischaemia: molecular mechanisms and therapeutic perspectives. Cardiovasc. Res. 2023;119(14):2405–2420. doi: 10.1093/cvr/cvad146. [ DOI ] [ PubMed ] [ Google Scholar ] 54. Han X., Simon M.C. NAD(+) regeneration drives cancer cell proliferation. Nat. Metab. 2022;4(6):647–648. doi: 10.1038/s42255-022-00586-w. [ DOI ] [ PubMed ] [ Google Scholar ] 55. Zhou L., Liu H., Chen Z., et al. Downregulation of miR-182-5p by NFIB promotes NAD+ salvage synthesis in colorectal cancer by targeting NAMPT. Commun. Biol. 2023;6(1):775. doi: 10.1038/s42003-023-05143-z. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 56. Wang Z., Lu Z., Lin S., et al. Leucine-tRNA-synthase-2-expressing B cells contribute to colorectal cancer immunoevasion. Immunity. 2022;55(6):1067–1081.e8. doi: 10.1016/j.immuni.2022.04.017. [ DOI ] [ PubMed ] [ Google Scholar ] 57. Thio S.S., Bonventre J.V., Hsu S.I. The CtBP2 co-repressor is regulated by NADH-dependent dimerization and possesses a novel N-terminal repression domain. Nucleic Acids Res. 2004;32(5):1836–1847. doi: 10.1093/nar/gkh344. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 58. Fantin V.R., St-Pierre J., Leder P. Attenuation of LDH-A expression uncovers a link between glycolysis, mitochondrial physiology, and tumor maintenance. Cancer Cell. 2006;9(6):425–434. doi: 10.1016/j.ccr.2006.04.023. [ DOI ] [ PubMed ] [ Google Scholar ] 59. Le A., Cooper C.R., Gouw A.M., et al. Inhibition of lactate dehydrogenase A induces oxidative stress and inhibits tumor progression. Proc. Natl. Acad. Sci. U. S. A. 2010;107(5):2037–2042. doi: 10.1073/pnas.0914433107. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 60. Baird L., Swift S., Llères D., et al. Monitoring Keap1-Nrf2 interactions in single live cells. Biotechnol. Adv. 2014;32(6):1133–1144. doi: 10.1016/j.biotechadv.2014.03.004. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 61. Li J., Qi F., Su H., et al. GRP75-faciliated Mitochondria-associated ER membrane (MAM) integrity controls cisplatin-resistance in ovarian cancer patients. Int. J. Biol. Sci. 2022;18(7):2914–2931. doi: 10.7150/ijbs.71571. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 62. Liang S.P., Wang X.Z., Piao M.H., et al. Activated SIRT1 contributes to DPT-induced glioma cell parthanatos by upregulation of NOX2 and NAT10. Acta Pharmacol. Sin. 2023;44(10):2125–2138. doi: 10.1038/s41401-023-01109-3. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 63. Yao J., Liang X., Xu S., et al. TRAF2 inhibits senescence in hepatocellular carcinoma cells via regulating the ROMO1/NAD(+)/SIRT3/SOD2 axis. Free Radic. Biol. Med. 2024;211:47–62. doi: 10.1016/j.freeradbiomed.2023.11.035. [ DOI ] [ PubMed ] [ Google Scholar ] 64. Chen X., Wang Z., Li C., et al. SIRT1 activated by AROS sensitizes glioma cells to ferroptosis via induction of NAD+ depletion-dependent activation of ATF3. Redox Biol. 2024;69 doi: 10.1016/j.redox.2024.103030. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 65. Patel J., Baranwal S., Love I.M., et al. Inhibition of C-terminal binding protein attenuates transcription factor 4 signaling to selectively target colon cancer stem cells. Cell Cycle. 2014;13(22):3506–3518. doi: 10.4161/15384101.2014.958407. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 66. Morandi F., Horenstein A.L., Malavasi F. The key role of NAD(+) in anti-tumor immune response: an update. Front. Immunol. 2021;12 doi: 10.3389/fimmu.2021.658263. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 67. Fang J., Chen W., Hou P., et al. NAD(+) metabolism-based immunoregulation and therapeutic potential. Cell Biosci. 2023;13(1):81. doi: 10.1186/s13578-023-01031-5. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 68. Wang Y., Wang F., Wang L., et al. NAD(+) supplement potentiates tumor-killing function by rescuing defective TUB-mediated NAMPT transcription in tumor-infiltrated T cells. Cell Rep. 2021;36(6) doi: 10.1016/j.celrep.2021.109516. [ DOI ] [ PubMed ] [ Google Scholar ] 69. Solier S., Müller S., Cañeque T., et al. A druggable copper-signalling pathway that drives inflammation. Nature. 2023;617(7960):386–394. doi: 10.1038/s41586-023-06017-4. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 70. Liu P.S., Chen Y.T., Li X., et al. CD40 signal rewires fatty acid and glutamine metabolism for stimulating macrophage anti-tumorigenic functions. Nat. Immunol. 2023;24(3):452–462. doi: 10.1038/s41590-023-01430-3. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 71. Guo X., Tan S., Wang T., et al. NAD + salvage governs mitochondrial metabolism, invigorating natural killer cell antitumor immunity. Hepatology. 2023;78(2):468–485. doi: 10.1002/hep.32658. [ DOI ] [ PubMed ] [ Google Scholar ] 72. Myong S., Nguyen A.Q., Challa S. Biological functions and therapeutic potential of NAD(+) metabolism in gynecological cancers. Cancers (Basel) 2024;16(17) doi: 10.3390/cancers16173085. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 73. Lv H., Lv G., Chen C., et al. NAD(+) metabolism maintains inducible PD-L1 expression to drive tumor immune evasion. Cell Metab. 2021;33(1):110–127.e5. doi: 10.1016/j.cmet.2020.10.021. [ DOI ] [ PubMed ] [ Google Scholar ] 74. Lu X., Jin P., Tang Q., et al. NAD(+) metabolism reprogramming drives SIRT1-Dependent deacetylation inducing PD-L1 nuclear localization in cervical cancer. Adv. Sci. (Weinh.) 2025;12(15) doi: 10.1002/advs.202412109. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 75. Xu Q., Liu X., Mohseni G., et al. Mechanism research and treatment progress of NAD pathway related molecules in tumor immune microenvironment. Cancer Cell Int. 2022;22(1):242. doi: 10.1186/s12935-022-02664-1. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 76. Audrito V., Managò A., Gaudino F., et al. NAD-Biosynthetic and consuming enzymes as central players of metabolic regulation of innate and adaptive immune responses in cancer. Front. Immunol. 2019;10:1720. doi: 10.3389/fimmu.2019.01720. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 77. Sumiyoshi A., Shibata S., Zhelev Z., et al. Targeting glioblastoma via selective alteration of mitochondrial redox state. Cancers (Basel) 2022;14(3) doi: 10.3390/cancers14030485. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 78. Ackermann T., Zuidhof H.R., Müller C., et al. C/EBPβ-LIP mediated activation of the malate-aspartate shuttle sensitizes cells to glycolysis inhibition. Mol. Metabol. 2023;72 doi: 10.1016/j.molmet.2023.101726. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 79. Bonnay F., Veloso A., Steinmann V., et al. Oxidative metabolism drives immortalization of neural stem cells during tumorigenesis. Cell. 2020;182(6):1490–1507.e19. doi: 10.1016/j.cell.2020.07.039. [ DOI ] [ PubMed ] [ Google Scholar ] 80. He D., Xin T., Pang B., et al. A novel lncRNA MDHDH suppresses glioblastoma multiforme by acting as a scaffold for MDH2 and PSMA1 to regulate NAD+ metabolism and autophagy. J. Exp. Clin. Cancer Res. 2022;41(1):349. doi: 10.1186/s13046-022-02543-7. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 81. Vamecq J., Masso V., Bancel L.P., et al. Serum fatty acid profiling in patients with SDHx mutations: new advances on cellular metabolism in SDH deficiency. Biochimie. 2022;201:196–203. doi: 10.1016/j.biochi.2022.07.008. [ DOI ] [ PubMed ] [ Google Scholar ] 82. Cortés-Rojo C., Vargas-Vargas M.A., Olmos-Orizaba B.E., et al. Interplay between NADH oxidation by complex I, glutathione redox state and sirtuin-3, and its role in the development of insulin resistance. Biochim. Biophys. Acta Mol. Basis Dis. 2020;1866(8) doi: 10.1016/j.bbadis.2020.165801. [ DOI ] [ PubMed ] [ Google Scholar ] 83. Yang Y., He P., Hou Y., et al. Osmundacetone modulates mitochondrial metabolism in non-small cell lung cancer cells by hijacking the glutamine/glutamate/α-KG metabolic axis. Phytomedicine. 2022;100 doi: 10.1016/j.phymed.2022.154075. [ DOI ] [ PubMed ] [ Google Scholar ] 84. Liu X., Liu Y., Liu Z., et al. CircMYH9 drives colorectal cancer growth by regulating serine metabolism and redox homeostasis in a p53-dependent manner. Mol. Cancer. 2021;20(1):114. doi: 10.1186/s12943-021-01412-9. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 85. Chen W.J., Huang R.S. Low-folate stress reprograms cancer stem cell-like potentials and bioenergetics metabolism through activation of mTOR signaling pathway to promote in vitro invasion and in vivo tumorigenicity of lung cancers. J. Nutr. Biochem. 2018;53:28–38. doi: 10.1016/j.jnutbio.2017.10.001. [ DOI ] [ PubMed ] [ Google Scholar ] 86. Liu Y., Yu J., An X., et al. TSA attenuates the progression of c-Myc-driven hepatocarcinogenesis by pAKT-ADH4 pathway. BMC Cancer. 2024;24(1):1049. doi: 10.1186/s12885-024-12781-x. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 87. He X., Wu N., Li R., et al. IDH2, a novel target of OGT, facilitates glucose uptake and cellular bioenergy production via NF-κB signaling to promote colorectal cancer progression. Cell. Oncol. 2023;46(1):145–164. doi: 10.1007/s13402-022-00740-2. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 88. Zhou X., Curbo S., Li F., et al. Inhibition of glutamate oxaloacetate transaminase 1 in cancer cell lines results in altered metabolism with increased dependency of glucose. BMC Cancer. 2018;18(1):559. doi: 10.1186/s12885-018-4443-1. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 89. Allison S.J., Knight J.R., Granchi C., et al. Identification of LDH-A as a therapeutic target for cancer cell killing via (i) p53/NAD(H)-dependent and (ii) p53-independent pathways. Oncogenesis. 2014;3(5) doi: 10.1038/oncsis.2014.16. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 90. Igelmann S., Lessard F., Uchenunu O., et al. A hydride transfer complex reprograms NAD metabolism and bypasses senescence. Mol. Cell. 2021;81(18):3848–3865.e19. doi: 10.1016/j.molcel.2021.08.028. [ DOI ] [ PubMed ] [ Google Scholar ] 91. Cheng T., Wang C., Lu Q., et al. Metformin inhibits the tumor-promoting effect of low-dose resveratrol, and enhances the anti-tumor activity of high-dose resveratrol by increasing its reducibility in triple negative breast cancer. Free Radic. Biol. Med. 2022;180:108–120. doi: 10.1016/j.freeradbiomed.2022.01.010. [ DOI ] [ PubMed ] [ Google Scholar ] 92. Han P., Zhang B., Li Y., et al. MiR-183-5p inhibits lung squamous cell carcinoma survival through disrupting hypoxia adaptation mediated by HIF-1α/NDUFA4L2 axis. Oncogene. 2024;43(38):2821–2834. doi: 10.1038/s41388-024-03129-7. [ DOI ] [ PubMed ] [ Google Scholar ] 93. Gandhi V.V., Gandhi K.A., Kumbhare L.B., et al. 3,3'-Diselenodipropionic acid (DSePA) induces reductive stress in A549 cells triggering p53-independent apoptosis: a novel mechanism for diselenides. Free Radic. Biol. Med. 2021;175:1–17. doi: 10.1016/j.freeradbiomed.2021.08.017. [ DOI ] [ PubMed ] [ Google Scholar ] 94. Ghanem M.S., Caffa I., Monacelli F., et al. Inhibitors of NAD(+) production in cancer treatment: state of the art and perspectives. Int. J. Mol. Sci. 2024;25(4) doi: 10.3390/ijms25042092. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 95. Bi T.Q., Che X.M. Nampt/PBEF/visfatin and cancer. Cancer Biol. Ther. 2010;10(2):119–125. doi: 10.4161/cbt.10.2.12581. [ DOI ] [ PubMed ] [ Google Scholar ] 96. Von Heideman A., Berglund A., Larsson R., et al. Safety and efficacy of NAD depleting cancer drugs: results of a phase I clinical trial of CHS 828 and overview of published data. Cancer Chemother. Pharmacol. 2010;65(6):1165–1172. doi: 10.1007/s00280-009-1125-3. [ DOI ] [ PubMed ] [ Google Scholar ] 97. Holen K., Saltz L.B., Hollywood E., et al. The pharmacokinetics, toxicities, and biologic effects of FK866, a nicotinamide adenine dinucleotide biosynthesis inhibitor. Invest. N. Drugs. 2008;26(1):45–51. doi: 10.1007/s10637-007-9083-2. [ DOI ] [ PubMed ] [ Google Scholar ] 98. Kim M., Kim H., Kang B.G., et al. Discovery of a novel NAMPT inhibitor that selectively targets NAPRT-deficient EMT-subtype cancer cells and alleviates chemotherapy-induced peripheral neuropathy. Theranostics. 2023;13(14):5075–5098. doi: 10.7150/thno.85356. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 99. Tang H., Wang L., Wang T., et al. Recent advances of targeting nicotinamide phosphoribosyltransferase (NAMPT) for cancer drug discovery. Eur. J. Med. Chem. 2023;258 doi: 10.1016/j.ejmech.2023.115607. [ DOI ] [ PubMed ] [ Google Scholar ] 100. Altinok O., Poggio J.L., Stein D.E., et al. Malate-aspartate shuttle promotes l-lactate oxidation in mitochondria. J. Cell. Physiol. 2020;235(3):2569–2581. doi: 10.1002/jcp.29160. [ DOI ] [ PubMed ] [ Google Scholar ] 101. Lou Y., Lou Y., Cheng Y., et al. Panoramic view of MDH1: driving cancer progression and shaping the tumor immune microenvironment. Front. Immunol. 2025;16 doi: 10.3389/fimmu.2025.1631449. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 102. Yang R., Li B., Fu Y., et al. Sonogenic malate depleting modulator for tumor metabolic reprogramming and antitumor immune activation. Bioact. Mater. 2026;56:682–702. doi: 10.1016/j.bioactmat.2025.10.028. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 103. Khan A., Valli E., Lam H., et al. Targeting metabolic activity in high-risk neuroblastoma through monocarboxylate Transporter 1 (MCT1) inhibition. Oncogene. 2020;39(17):3555–3570. doi: 10.1038/s41388-020-1235-2. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 104. Vellama H., Eskla K.L., Eichelmann H., et al. VHL-deficiency leads to reductive stress in renal cells. Free Radic. Biol. Med. 2023;208:1–12. doi: 10.1016/j.freeradbiomed.2023.07.029. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 105. Saveljeva S., Sewell G.W., Ramshorn K., et al. A purine metabolic checkpoint that prevents autoimmunity and autoinflammation. Cell Metab. 2022;34(1):106–124.e10. doi: 10.1016/j.cmet.2021.12.009. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 106. Jaiswal A., Singh R. A negative feedback loop underlies the warburg effect. NPJ Syst Biol Appl. 2024;10(1):55. doi: 10.1038/s41540-024-00377-x. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 107. Liang K., Nan F., Wang J., et al. A versatile nanozyme-based NADH circulating oxidation reactor for tumor therapy through triple cellular metabolism disruption. Small. 2024;20(26) doi: 10.1002/smll.202311027. [ DOI ] [ PubMed ] [ Google Scholar ] 108. Rigoulet M., Bouchez C.L., Paumard P., et al. Cell energy metabolism: an update. Biochim. Biophys. Acta Bioenerg. 2020;1861(11) doi: 10.1016/j.bbabio.2020.148276. [ DOI ] [ PubMed ] [ Google Scholar ] 109. Schnepp P.M., Lee D.D., Guldner I.H., et al. GAD1 upregulation programs aggressive features of cancer cell metabolism in the brain metastatic microenvironment. Cancer Res. 2017;77(11):2844–2856. doi: 10.1158/0008-5472.CAN-16-2289. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 110. Li Y., Sun J., Ni X., et al. Fluorescent probe for simultaneous monitoring of ONOO(-) and NAD(P)H reveals dynamic cellular redox fluctuations. Anal. Chem. 2026;98(4):3071–3080. doi: 10.1021/acs.analchem.5c06337. [ DOI ] [ PubMed ] [ Google Scholar ] 111. Yang M., Mahanty A., Jin C., et al. Label-free metabolic imaging for sensitive and robust monitoring of anti-CD47 immunotherapy response in triple-negative breast cancer. J. Immunother. Cancer. 2022;10(9) doi: 10.1136/jitc-2022-005199. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement No data was used for the research described in the article. Articles from Redox Biology are provided here courtesy of Elsevier ACTIONS View on publisher site PDF (5.0 MB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top