# The unfolded protein response influences therapy outcome and disease progression in chronic lymphocytic leukaemia

## TL;DR

This study shows that the unfolded protein response affects treatment success and disease progression in chronic lymphocytic leukemia.

## Contribution

The unfolded protein response (UPR) is identified as a novel determinant of therapy outcome in chronic lymphocytic leukemia (CLL).

## Key findings

- eIF2 signaling, central to the UPR, was the most enriched pathway in CLL samples and resistant cell lines.
- Fludarabine-resistant CLL cells showed higher PERK and lower BiP levels, indicating UPR activation.
- A PERK inhibitor sensitized resistant CLL cells to fludarabine without harming normal cell viability.

## Abstract

Since genomics, epigenomics and transcriptomics have provided only a partial explanation of chronic lymphocytic leukaemia (CLL) heterogeneity, and since concordance between mRNA and protein expression is incomplete, we related the CLL proteome to clinical outcome. CLL samples from patients who received fludarabine-containing chemoimmunotherapy were analysed by mass spectrometry (SWATH-MS). One dataset compared pre-treatment samples associated with an optimal versus suboptimal response, while another compared paired samples collected before treatment and at disease progression. eIF2 signalling (pivotal to the unfolded protein response (UPR)), was identified as the most enriched pathway in both datasets (respective z-scores: − 6.245 and 3.317; p < 0.0001), as well as in a fludarabine-resistant CLL cell line established from HG3 cells (z-score: − 2.121; p < 0.0001). Western blotting revealed that fludarabine-resistant HG3 cells expressed higher levels of PERK, which phosphorylates the regulatory eIF2α subunit, and lower levels of BiP, an HSP70 molecular chaperone that inactivates PERK but preferentially binds to misfolded proteins during ER stress. The PERK inhibitor, GSK2606414, sensitised resistant, but not sensitive, HG-3 cells to fludarabine without affecting background cell viability or cytotoxicity induced by the BCL-2 inhibitor venetoclax. These findings identify the UPR as a novel determinant of therapy outcome and disease progression in CLL.

The online version contains supplementary material available at 10.1038/s41598-025-13495-1.