D-lactate and glycerol as potential biomarkers of sorafenib activity in hepatocellular carcinoma.

Sorafenib, a multi-kinase inhibitor for advanced hepatocellular carcinoma (HCC), often encounters resistance within months of treatment, limiting its long-term efficacy. Despite extensive efforts, reliable plasma biomarkers to monitor drug activity remain elusive. Here, we demonstrate that metabolic reprogramming is a strategic response implemented by cancer cells to survive the therapeutic pressure. Sorafenib suppresses oxidative phosphorylation by disrupting electron transport chain supercomplex assembly and enhancing glycolysis. To mitigate the accumulation of harmful glycolytic byproducts such as advanced glycation end-products (AGEs), sorafenib-treated cells reroute excess dihydroxyacetone phosphate (DHAP) toward glycerol-3-phosphate (G3P) synthesis, supporting glycerolipid metabolism, NAD regeneration, and redox balance, rather than producing D-lactate via the glyoxalase pathway. Alongside, resistant cells enhance serine metabolism to boost glutathione synthesis, reinforcing antioxidant defenses. Additionally, sorafenib increases reliance on exogenous non-esterified free fatty acids and triglycerides for phospholipid remodeling. The combined effects of glycerolipid remodeling and enhanced antioxidant capacity facilitate ferroptosis escape, diminishing sorafenib's activity. Leveraging these metabolic insights, we validate our findings by investigating plasma metabolites alteration in HCC patients. We identify D-lactate accumulation as a predictor of treatment response and glycerol accumulation as a marker of resistance, highlighting their potential as novel biomarkers for sorafenib activity. As sorafenib is used in advanced HCC, early detection of treatment response is critical to guiding the therapeutic decision, optimizing treatment strategies, and improving patient outcomes.