INNATE IMMUNITY AND DOXORUBICIN-CARDIOMYOPATHY.

Rationale: Cytokines such as TNFα have been implicated in cardiac dysfunction and toxicity associated with doxorubicin (DOX). While TNFα can elicit different cellular responses including survival or death, the mechanisms underlying these divergent outcomes in the heart remains cryptic. The E3 ubiquitin ligase TRAF2 provides a critical signaling platform for K63 - linked ubiquitination of RIPK1, crucial for NF-kB activation by TNFα. Whether alterations in TNFα-TRAF2 signaling underlie the cardiotoxic effects of DOX, remains poorly understood.
Objective: To investigate TRAF2 signaling in the pathogenesis of DOX cardiotoxicity.
Methods: Using a combination of in vivo (4 weekly injections of DOX (5mg/kg/week) in cardiac-myocyte restricted expression of AAV9-GFP and AAV9-TRAF2 mice (C57/BL6J), and in vitro approaches (rat, mouse and human iPSCs derived cardiac myocytes), we monitored TNFα levels, LDH, cardiac ultrastructure and function, mitochondrial bioenergetics and cardiac cell viability.
Results: In contrast to vehicle treated mice, severe ultrastructural defects including cytoplasmic swelling, mitochondrial perturbations, and elevated TNFa levels were observed in the hearts of mice treated with DOX. While investigating the involvement of TNFa in DOX cardiotoxicity, we discovered that in the absence of DOX, NF-kB was readily activated by TNFa. However, TNFα -mediated NF-kB activation was impaired in cardiac myocytes treated with DOX. This coincided with loss of K63- linked poly-ubiquitination of RIPK1, attributed to the proteasomal degradation of TRAF2. Further, TRAF2 protein expression was markedly reduced in hearts of cancer patients treated with DOX. Impaired TRAF2 signaling resulted in the activation of Bnip3 and mitochondrial perturbations, including disrupted bioenergetics, loss of membrane potential and permeability transition pore opening. We further established that the reciprocal actions of the ubiquitinating and de-ubiquitinating enzymes c-IAP1 and USP19 respectively regulated the proteasomal degradation of TRAF2 in DOX treated cardiac myocytes. Importantly, an E3 ligase mutant of c-IAP1(c-IAP1 H588A) or gain of function of USP19, prevented proteasomal degradation of TRAF2 and DOX -induced cell death. Further, wild type TRAF2 but not a RING finger mutant defective for K63 ubiquitination of RIPK1, restored NF-kB signaling and suppressed DOX-induced cardiac cell death. Finally, cardiomyocyte-restricted expression of TRAF2 (AAV9-TRAF2) in vivo protected against mitochondrial defects and cardiac dysfunction induced by DOX.
Conclusions: Our findings reveal a novel signaling axis that functionally connects the cardiotoxic effects of DOX to proteasomal degradation of TRAF2. Disruption of the critical TRAF2 survival pathway by DOX, sensitized cardiac myocytes to TNFa mediated necrotic cell death.