Azacitidine-resistant SKM1 myeloid cells are defective for AZA-induced mitochondrial apoptosis and autophagy.

Azacitidine (AZA) is the current treatment for patients with high-risk myelodysplastic syndrome, but resistance is a common feature of AZA-treated patients. To investigate the mechanisms associated with AZA resistance in vitro, we generated AZA-resistant SKM1 myeloid cells, called hereafter AZA-R. AZA-R cells exhibit impaired mitochondrial membrane permeabilization and caspase activation in response to AZA compared to their AZA-sensitive (AZA-S) counterpart. AZA induced LC3-II accumulation and cathepsin B activity in AZA-S cells, two hallmarks of autophagy. AZA-R cells displayed increased basal autophagy but are resistant to AZA-mediated autophagy. Inhibition of autophagy using LC3 siRNA revealed that autophagy is protective in AZA-S cells and AZA-R cells in basal conditions. By contrast, AZA-R cells exhibited impaired autophagy in response to AZA. Collectively, our findings indicate that AZA promotes apoptosis and autophagy in SKM1 cells, and that AZA-R cells are resistant to both apoptosis and autophagy induced by AZA.