The functions, mechanisms and clinical relevance of RNA and protein acetyltransferase NAT10: a comprehensive review.

While previous studies have primarily focused on the molecular functions of NAT10, translating these findings into clinical applications requires integration with system-level perspectives to better understand its potential roles across diverse disease contexts. Here, we summarize the roles of NAT10 across several major physiological systems, including the circulatory, reproductive, locomotor, immune, and nervous systems, while also providing a brief overview of its functions in other biological systems. The circulatory system, also referred to as the cardiovascular system, plays a central role in maintaining physiological homeostasis (Liberale et al. 2025 ). It comprises a complex and highly coordinated network that supports blood circulation and systemic homeostasis. This system consists primarily of the heart, the vascular network (including arteries, veins, and capillaries), and circulating blood components such as red blood cells, white blood cells, and platelets (Zhuang et al. 2024 ). Recent studies indicate that NAT10 plays a dual regulatory role within the cardiovascular system, with its functions varying substantially under physiological and pathological conditions (Fig.  3 ). Fig. 3 Roles of NAT10 in the circulatory system. In the normal heart, NAT10-dependent ac4C modification of Kmt5a and Bcl-XL mRNAs regulates p53 and caspase 3 signaling, thereby affecting cardiomyocyte apoptosis and cardiac fibroblast activation. In heart failure, NAT10 modifies Amotl1 and Mybbp1a mRNAs through ac4C, modulating the AMOTL1/YAP and MYBBP1A/p53/SLC7A11 pathways to influence fibroblast activation and cardiomyocyte ferroptosis. ac4C, N4-acetylcytidine Roles of NAT10 in the circulatory system. In the normal heart, NAT10-dependent ac4C modification of Kmt5a and Bcl-XL mRNAs regulates p53 and caspase 3 signaling, thereby affecting cardiomyocyte apoptosis and cardiac fibroblast activation. In heart failure, NAT10 modifies Amotl1 and Mybbp1a mRNAs through ac4C, modulating the AMOTL1/YAP and MYBBP1A/p53/SLC7A11 pathways to influence fibroblast activation and cardiomyocyte ferroptosis. ac4C, N4-acetylcytidine NAT10 plays a crucial role in cardiac development and function by maintaining the expression of genes involved in fatty acid β-oxidation and cardiac contractility (Shi et al. 2026 ). Loss of NAT10 disrupts cardiac metabolic homeostasis and contractile capacity, ultimately leading to cardiomyocyte dysfunction and heart failure. Genetic ablation of NAT10 reduces ac4C modification of KMT5A mRNA, activates p53 signaling, and promotes cardiomyocyte apoptosis, ultimately leading to heart failure. (Xu et al. 2024 ). In ischemic heart disease, NAT10 also regulates mitochondrial gene expression independently of its ac4C catalytic activity by reducing the nuclear export and translation of mitochondrial respiratory components such as Uqcrb and Uqcr11. The resulting impairment of mitochondrial respiration enhances glycolytic activity and metabolic reprogramming in cardiomyocytes, which may transiently promote cardiomyocyte proliferation and cardiac repair. Both Remodelin treatment and cardiomyocyte-specific depletion of NAT10 were reported to impair heart regeneration (Ma et al. 2024a ). The concordant genetic phenotype supports the involvement of NAT10 in this process, although the Remodelin result alone does not establish on-target pharmacological inhibition. However, the specificity of Remodelin for NAT10 has been questioned, as it did not reduce NAT10-dependent ac4C in cellular assays and showed no direct binding to the catalytic pocket (Shrimp et al. 2021 ). During myocardial ischemia–reperfusion injury, activation of the p53 signaling pathway stimulates NAT10-dependent ac4C modification of Mybbp1a mRNA, enhancing its stability and translation. This further amplifies p53 signaling and represses the ferroptosis inhibitor SLC7A11, thereby aggravating ferroptotic cardiomyocyte death (Qu et al. 2024 ). NAT10-mediated ac4C modification stabilizes SOAT1 mRNA, leading to increased SOAT1 expression. Elevated SOAT1 enhances acetylation and stabilization of NCOA4, triggering NCOA4-dependent ferroautophagy and ferroptosis in cardiomyocytes (Deng et al. 2025 ). Following myocardial infarction, NAT10 expression is significantly upregulated and contributes to cardiac fibrosis through multiple mechanisms. NAT10 enhances ac4C modification and stability of TGFBR1 mRNA, amplifying TGF-β signaling (Zhou et al. 2025 ). NAT10-mediated stabilization of Amotl1 mRNA further facilitates YES-associated protein 1 (YAP) nuclear translocation and fibrotic remodeling (Wang et al. 2024f ). NAT10 may also inhibit Caspase3 activation by enhancing BCL-XL mRNA acetylation, blocking cardiac fibroblast apoptosis and contributing to similar pathological outcomes (Li et al. 2024c ). Beyond myocardial injury, NAT10 also participates in vascular smooth muscle cell phenotypic switching, vascular remodeling, and vascular calcification (Yu et al. 2025 ; Sun et al. 2024 ). A deeper understanding of NAT10-dependent regulatory mechanisms in different cardiovascular cell types may help define its disease-specific functions. Such knowledge may guide the rational application of NAT10-targeted therapies while minimizing potential adverse effects. The reproductive system is central for human reproduction and contributes to endocrine homeostasis and the development of secondary sexual characteristics. Male and female reproductive organs, such as the testes, ovaries, vas deferens, and uterus, function in coordination to support gamete production, fertilization, and embryonic development (Lai et al. 2025 ). Emerging evidence indicates that NAT10 regulates multiple processes in the reproductive system and contributes to the functional maintenance of several reproductive organs (Fig.  4 ). Fig. 4 Roles of NAT10 in the reproductive system. HOXC8-induced NAT10 increases ac4C modification of FOXP1 mRNA, activating FOXP1-dependent GLUT4 and KHK signaling, promoting Treg differentiation and cervical cancer progression. NAT10-mediated ac4C modification of TGFB1 mRNA contributes to endometriosis. In prostate cancer, NAT10 regulates KRT8 and HMGA1 mRNAs through ac4C modification, thereby modulating cadherin expression, epithelial–mesenchymal transition, cell-cycle progression, proliferation, and metastasis. Red and blue arrows indicate increased and decreased expression or activity, respectively. ac4C, N4-acetylcytidine Roles of NAT10 in the reproductive system. HOXC8-induced NAT10 increases ac4C modification of FOXP1 mRNA, activating FOXP1-dependent GLUT4 and KHK signaling, promoting Treg differentiation and cervical cancer progression. NAT10-mediated ac4C modification of TGFB1 mRNA contributes to endometriosis. In prostate cancer, NAT10 regulates KRT8 and HMGA1 mRNAs through ac4C modification, thereby modulating cadherin expression, epithelial–mesenchymal transition, cell-cycle progression, proliferation, and metastasis. Red and blue arrows indicate increased and decreased expression or activity, respectively. ac4C, N4-acetylcytidine Dysregulated expression of NAT10 has been implicated in several disorders of the female reproductive system. NAT10 is significantly upregulated in endometrial lesions, where it stabilizes transforming growth factor β1 (TGF-β1) mRNA, promoting the progression of endometriosis (Liu et al. 2025a ). NAT10 also facilitates epithelial-mesenchymal transition (EMT) in cervical cancer by activating the JAK2/STAT3 signaling pathway, enhancing tumor cell invasion and metastasis. The precise mechanisms by which NAT10 regulates JAK2/STAT3 activation and EMT progression remain unclear (Chen et al. 2024b ). Additionally, HOXC8 has been reported to activate NAT10 transcription by binding to its promoter, thereby enhancing FOXP1 mRNA stability through ac4C modification. This regulatory axis increases the expression of GLUT4 and KHK, enhances glycolysis and lactate secretion in cervical cancer cells, and promotes the immunosuppressive activity of tumor-infiltrating regulatory T cells (Tregs) (Chen et al. 2023 ). In addition to its role in reproductive pathologies, NAT10 directly regulates oocyte maturation during meiosis. NAT10 mediates ac4C modification of O-GlcNAcase (OGA) mRNA, thereby regulating oocyte maturation and suggesting potential implications for improving in vitro maturation (IVM) strategies (Lin et al. 2022 ). Depletion of NAT10 prior to meiosis disrupts meiotic prophase I progression and leads to follicular arrest, premature ovarian failure, and infertility in adult females. Mechanistically, NAT10 promotes oocyte mRNA translation by mediating ac4C of CCR4-NOT complex transcripts, facilitating germinal vesicle (GV) chromatin remodeling and ensuring proper meiotic progression (Jiang et al. 2023 ). NAT10 also exerts regulatory roles in the male reproductive system. In prostate cancer, NAT10 enhances ac4C modification of HMGA1 and KRT8 mRNAs, increasing their stability and expression (Li et al. 2024d ). NAT10 inhibitors have also been shown to suppress prostate cancer cell growth under both castrate and non-castrate conditions by impairing DNA replication (Ma et al. 2022 ). Moreover, NAT10-mediated ac4C modification is required for the entry and progression of male germ cell meiosis (Chen et al. 2022 ). Current evidence suggests that systemic NAT10 inhibition may potentially interfere with germ cell meiosis. Therefore, strategies that enable tissue-specific targeting of NAT10 inhibitors may help reduce potential reproductive toxicity. Such approaches may limit nonspecific exposure of germ cells and preserve normal gametogenesis. The locomotor system, comprising bones, joints, and skeletal muscles, maintains body structure, supports mechanical load, protects internal organs, and enables movement. NAT10 plays a multifaceted role in the locomotor system, particularly in bone remodeling, bone homeostasis, osteosarcoma cell proliferation, and skeletal muscle function (Fig.  5 ). Fig. 5 Roles of NAT10 in the locomotor system. NAT10-dependent ac4C modification of RUNX2 mRNA promotes RUNX2 expression and osteogenic gene transcription, contributing to bone formation and osteoporosis regulation. In osteosarcoma, NAT10 enhances ac4C modification of YTHDC1 mRNA, while YTHDC1 regulates m6A-modified LDHA and PFKM transcripts to support tumor progression. NAT10 also increases Fos mRNA ac4C modification and activates AP-1 signaling, inducing osteoclast-related genes, including ACP5, CTSK, CALCR, ATP6V0D2, and MMP9. ac4C, N4-acetylcytidine; m6A, N6-methyladenosine Roles of NAT10 in the locomotor system. NAT10-dependent ac4C modification of RUNX2 mRNA promotes RUNX2 expression and osteogenic gene transcription, contributing to bone formation and osteoporosis regulation. In osteosarcoma, NAT10 enhances ac4C modification of YTHDC1 mRNA, while YTHDC1 regulates m6A-modified LDHA and PFKM transcripts to support tumor progression. NAT10 also increases Fos mRNA ac4C modification and activates AP-1 signaling, inducing osteoclast-related genes, including ACP5, CTSK, CALCR, ATP6V0D2, and MMP9. ac4C, N4-acetylcytidine; m6A, N6-methyladenosine NAT10 participates in skeletal homeostasis by mediating ac4C modification, regulating the differentiation balance between osteoblasts and osteoclasts, influencing bone remodeling. Excessive osteoclastogenesis is a key mechanism underlying inflammatory bone loss. NAT10 stabilizes Fos mRNA (encoding the AP-1 component c-Fos) through ac4C modification, maintaining its stability during osteoclast differentiation. Additionally, NAT10 activates the MAPK signaling pathway, further promotes AP-1 (c-Fos/c-Jun) transcriptional activity and osteoclastogenesis (Yang et al. 2025 ). Osteoblasts are derived from bone marrow mesenchymal stem cells (BMSCs). NAT10 catalyzes ac4C modification of RUNX2 mRNA, promoting BMSC differentiation into osteoblasts. In an ovariectomized (OVX) mouse model of osteoporosis, adenovirus-mediated overexpression of NAT10 significantly reversed bone loss, whereas Remodelin treatment was associated with more severe bone loss, consistent with impaired osteoblast differentiation (Yang et al. 2021 ). Excessive NAT10 activity promotes osteoclastogenesis and bone resorption, while inhibition of NAT10 activity may suppress osteoblast differentiation. Furthermore, downregulation of NAT10 has been shown to inhibit ac4C acetylation, reducing osteosarcoma cell proliferation and metastasis (Zhang et al. 2023b ). NAT10 also modulates m6A modification through ac4C modification of YTHDC1, which recognizes differential m6A sites on key glycolytic enzymes, such as phosphofructokinase (PFKM) and lactate dehydrogenase A (LDHA), in an m6A methylation-dependent manner. This process enhances mRNA stability, promotes osteosarcoma cell growth, and regulates glycolytic pathways (Mei et al. 2024 ). Recent studies have also implicated NAT10 in intervertebral disc degeneration (IVDD). Under oxidative stress, NAT10 enhances ac4C modification of IKKβ mRNA, activating NF-κB signaling and promoting nucleus pulposus cell apoptosis and extracellular matrix degradation (Wang et al. 2025b ). Polyethylene microplastics transported to nucleus pulposus cells via macrophage-derived exosomes disrupt the NAT10/SLC7A11 regulatory axis. This process increases oxidative stress, ferroptosis, and cellular senescence in nucleus pulposus cells, thereby accelerating IVDD progression (Zhang et al. 2025a ). NAT10 has also been implicated in skeletal muscle physiology. In Hutchinson-Gilford progeria syndrome models, Remodelin treatment was reported to improve abnormal nuclear architecture and ameliorate skeletal muscle degeneration and body-weight loss. In sepsis-induced muscle atrophy, Remodelin treatment and genetic or molecular suppression of NAT10 were each associated with reduced ROS/NLRP3 signaling and improved muscle phenotypes (Wang et al. 2023b ). However, the specificity of Remodelin for NAT10 has been questioned, as it did not reduce NAT10-dependent ac4C in cellular assays and showed no direct binding to the catalytic pocket (Shrimp et al. 2021 ). Therefore, the Remodelin-associated effects require confirmation using direct target-engagement assays and orthogonal NAT10 genetic perturbation. These findings highlight the diverse roles of NAT10 in the musculoskeletal system suggest that targeting NAT10 signaling may represent a potential therapeutic strategy for related disorders. Additionally, studies provide mechanistic insight into the molecular mechanisms underlying traditional Chinese medicine formulations. For example, the Mi Jiao (MJ) formula promotes BMSC osteogenic differentiation by modulating NAT10-mediated ac4C modification of RUNX2 mRNA, improving osteoporosis in ovariectomized rats (Xiao et al. 2024b ). The immune system is involved in host defense by recognizing and eliminating antigenic foreign bodies while coordinating with other physiological systems to maintain homeostasis (Wang et al. 2025c ). As an RNA acetyltransferase, NAT10 has a complex role in immune regulation, encompassing immune cell polarization, infiltration, tumor immune evasion, T-cell function modulation, and innate immune responses. Through its interactions with immune regulatory pathways, NAT10 plays a pivotal role in the pathogenesis and progression of various diseases, including cancer (Liu et al. 2024d ), sepsis (Zhang et al. 2022a ), and systemic lupus erythematosus (Guo et al. 2020 ) (Fig.  6 ). Fig. 6 Roles of NAT10 in immune regulation and infection. NAT10 promotes B-cell and plasma-cell survival through BCL-XL and PI3K–AKT signaling, while NAT10 inhibitors suppress HIV, EV71, and SINV replication. In tumors, NAT10-dependent ac4C modification of CCL2, CXCL2, and KLF5 mRNAs regulates macrophage infiltration, M2 polarization, and extracellular-matrix interactions. NAT10-mediated ac4C modification of GAS5 activates the MYBBP1A–p53–IRF1 pathway to enhance immune-cell recruitment, whereas the lncRNA-ENST00000421645–NAT10–14–3-3 axis suppresses NF-κB and IFN-γ signaling and promotes T-cell apoptosis. Red and blue arrows indicate increased and decreased expression or activity, respectively. ac4C, N4-acetylcytidine Roles of NAT10 in immune regulation and infection. NAT10 promotes B-cell and plasma-cell survival through BCL-XL and PI3K–AKT signaling, while NAT10 inhibitors suppress HIV, EV71, and SINV replication. In tumors, NAT10-dependent ac4C modification of CCL2, CXCL2, and KLF5 mRNAs regulates macrophage infiltration, M2 polarization, and extracellular-matrix interactions. NAT10-mediated ac4C modification of GAS5 activates the MYBBP1A–p53–IRF1 pathway to enhance immune-cell recruitment, whereas the lncRNA-ENST00000421645–NAT10–14–3-3 axis suppresses NF-κB and IFN-γ signaling and promotes T-cell apoptosis. Red and blue arrows indicate increased and decreased expression or activity, respectively. ac4C, N4-acetylcytidine In intrahepatic cholangiocarcinoma, NAT10 binds to C–C motif chemokine ligand 2 (CCL2) mRNA, promoting its protein expression and partially guiding macrophages toward M2 polarization through CCL2 secretion, thus facilitating tumor immune evasion (Cai et al. 2024 ). NAT10 also regulates macrophage polarization by modifying TLR9 mRNA with ac4C (Yin et al. 2024 ). Similarly, NAT10-mediated ac4C modification of CXCL2 and KLF5 influences CXCL2 secretion, which influencing the infiltration and polarization of M2-like macrophages (Chen et al. 2025 ). NAT10 also facilitates tumor immune evasion by acetylating the nucleophosmin 1 (NPM1) at the promoter region of programmed cell death ligand 1 (PD-L1), promoting PD-L1 transcription and suppressing the infiltration and function of CD8 + T-cells, aiding tumor cells in evading immune surveillance (Qin et al. 2024 ). In contrast, NAT10 mediates ac4C modification of the long non-coding RNA growth arrest-specific 5 (GAS5), significantly enhancing its stability and functional activity. Upon binding to MYBBP1A, GAS5 promotes the interaction between MYBBP1A and p53, leading to increased IRF1 transcriptional activity, activation of the type I interferon signaling pathway, and enhanced recruitment of macrophages and T cells, thereby promoting immune cell infiltration in NSCLC (Wang et al. 2024g ). In addition to its role in regulating immune cell infiltration, NAT10 exerts dual regulatory effects on T-cell proliferation and apoptosis, with its function regulated by upstream factors. In response to antigen stimulation, NAT10 modulates acetylation of RACK1 at the K185 residue, inhibiting the K48-linked ubiquitination and subsequent proteasomal degradation. Stabilized RACK1 alters ribosome formation and cellular metabolism, driving T-cell proliferation (Li et al. 2024e ). Notably, in patients with neurosyphilis, lncRNA-ENST00000421645 directly acts on NAT10 to promote histone H3K27 acetylation near the Kank1 promoter region. This process enhances 14–3-3 protein expression, inhibits NF-kB activation, reduces IFN-γ secretion in T lymphocytes, ultimately inducing T-cell apoptosis, aiding the immune evasion of Treponema pallidum and facilitating the development of neurosyphilis (Wu et al. 2021 ). In the B-lymphocyte/plasma cell lineage, NAT10 has been reported to upregulate BCL-XL (BCL2L1) and suppress apoptosis, accompanied by activation of PI3K–AKT signaling and increased cell-cycle progression and proliferation (Zhang et al. 2022b ). NAT10-dependent ac4C on GPR37 mRNA has also been linked to enhanced multiple myeloma growth, glycolysis, and immune evasion (Liu et al. 2025b ). In addition, NAT10 acetylates CEP170, increasing its translational efficiency and consequently modulating cell proliferation and cell-cycle distribution (Wei et al. 2022 ). Beyond its role in the tumor immune microenvironment, NAT10 is also involved in immune-related diseases such as rheumatoid arthritis (RA). In RA, NAT10 regulates the function of fibroblast-like synoviocytes by mediating N4-acetylation of pentraxin 3 (PTX3) mRNA, promoting immune cell infiltration within the synovium (Liu et al. 2024e ). Dysregulated or excessive T-cell proliferation can lead to autoimmune diseases. Interestingly, NAT10-mediated immune responses also participates in viral immune evasion. NAT10 inhibitors have demonstrated potential in suppressing viral replication in various viruses, including HIV (Tsai et al. 2020 ), enterovirus 71 (Hao et al. 2022 ), and Sindbis virus (SINV) (Dang et al. 2024 ). The Kaposi’s sarcoma-associated herpesvirus (KSHV) encoded polyadenylated nuclear RNA (PAN) coordinates with NAT10 and α-tubulin acetyltransferase 1 (ATAT1) to enhance NAT10-mediated lactylation, promoting KSHV lytic protein translation and viral reactivation (Yan et al. 2024 ). NAT10 also stabilizes PAN through ac4C modification. Acetylated PAN further recruits interferon-γ inducible protein 16 (IFI16) mRNA, enhancing its ac4C modification and protein expression, ultimately activating the innate inflammasome (Yan et al. 2023 ). Targeting NAT10 could be exploited for the treatment of immune-related diseases, and could be combined with current immunotherapies to enhance their effectiveness (Qin et al. 2024 ; Chen et al. 2023 ). Moreover, targeting NAT10 may provide novel strategies for antiviral therapy, helping to improve immune responses following viral infections and reducing the risk of persistent viral infections and immune evasion. The nervous system is the central regulatory system of the body, coordinating the activities of multiple organs and physiological systems. NAT10-mediated ac4C modification plays a significant role in both the physiological and pathological processes of the nervous system, particularly in the differentiation and functional maintenance of neural cells, influencing neural development and functional stability (Fig.  7 ). Fig. 7 Roles of NAT10 in the nervous system. During neural development, NAT10 uses acetyl-CoA to increase NR2F1 mRNA stability and translation, promoting YAP1 nuclear export. In neuropathic pain, USF1-induced NAT10 enhances SYT9 mRNA ac4C modification and SYT9 expression, contributing to hyperalgesia and pain sensitization. In cognitive and affective dysfunction, NAT10-dependent ac4C regulation increases GABABR1 expression, enhances inhibitory postsynaptic currents, and promotes microglial inflammatory activation. Pink spheres indicate SYT9-associated secretory vesicles and released nociceptive mediators; green spheres indicate inflammatory mediators released by activated microglia Roles of NAT10 in the nervous system. During neural development, NAT10 uses acetyl-CoA to increase NR2F1 mRNA stability and translation, promoting YAP1 nuclear export. In neuropathic pain, USF1-induced NAT10 enhances SYT9 mRNA ac4C modification and SYT9 expression, contributing to hyperalgesia and pain sensitization. In cognitive and affective dysfunction, NAT10-dependent ac4C regulation increases GABABR1 expression, enhances inhibitory postsynaptic currents, and promotes microglial inflammatory activation. Pink spheres indicate SYT9-associated secretory vesicles and released nociceptive mediators; green spheres indicate inflammatory mediators released by activated microglia Germ layer differentiation is a key step in embryonic development, during which the ectoderm gives rise to the epidermis and nervous system. It has been reported that NAT10, through ac4C modification of OCT mRNA, maintains the self-renewal of human embryonic stem cells (hESCs) and prevents premature differentiation (Liu et al. 2023 ). Ge et al. used hESCs to simulate early embryonic development and found that NAT10-mediated ac4C modification enhances the stability and translation of nuclear receptor subfamily 2 F group member 1 (NR2F1) mRNA, which promoting the nuclear export of yes-associated protein 1 (YAP1), accelerating ectoderm differentiation in hESCs, and influencing nervous system development (Ge et al. 2024 ). NAT10 participates in the induction and exacerbation of neuropathic pain through ac4C modification. In thalamic neurons, NAT10 is upregulated following thalamic hemorrhage (TH), promoting ac4C modification of fibroblast growth factor-inducible 14 (Fn14) mRNA and activating the NF-κB signaling pathway, which triggering hyperalgesic responses closely associated with TH-induced post-stroke pain (Huang et al. 2025a ). After peripheral nerve injury, the transcription factor upstream transcription factor 1 (USF1) binds to the NAT10 promoter in injured dorsal root ganglia, promoting NAT10 upregulation. The increased NAT10 enhances the ac4C modification of Syt9 mRNA, promoting SYT9 protein expression and exacerbating hyperalgesic responses (Zhang et al. 2023c ). Moreover, HNRNPK recruits NAT10 to Vegfa mRNA in dorsal horn neurons, enhancing its ac4C modification and promoting its interaction with polyribosomes, thus increasing translation efficiency, enhancing spinal cord sensitization, and contributing to neuropathic pain (Xu et al. 2023 ). Given the role of NAT10 in neuropathic pain, the development of drugs specifically targeting NAT10-mediated regulation of neuronal pain pathways may offer new therapeutic strategies for chronic pain. Targeting NAT10 at either the RNA or protein level may confer therapeutic benefits across a broader spectrum of neurological disorders (Shibagaki et al. 2024 ; Ceccanti and Inghilleri 2024 ). In a murine model of sepsis-associated encephalopathy, microglial activation and the release of inflammatory mediators promoted the expression of NAT10 in neurons. NAT10 promotes GABABR1 expression through mRNA acetylation, enhancing inhibitory postsynaptic currents in hippocampal DG neurons, ultimately leading to cognitive dysfunction (Gao et al. 2024 ). In studies on chronic mild stress-induced anxiety and depression-like behaviors in mice, researchers found that neuron-specific overexpression of NAT10 in the hippocampus increased silent information regulator 1 (SIRT1) and reduced dendritic spine density, leading to anxiety and depression-like behaviors (Guo et al. 2022 ). In addition to its critical roles in the aforementioned systems, NAT10 also plays a key role in endocrine systems (Fig.  8 A), respiratory (Fig.  8 B), digestive (Fig.  8 C) and urinary (Fig.  8 D). Fig. 8 Roles of NAT10 in other biological systems. ( A ) Endocrine and metabolic regulation: NAT10-associated ac4C affects transcripts involved in fatty-acid synthesis, uptake, adipogenesis, and ferroptosis. ( B ) Respiratory system: NAT10-mediated ac4C of TGFB1, HMGB1, or TFRC mRNAs has been linked to epithelial-mesenchymal transition, inflammation, mitochondrial dysfunction, and ferroptosis. ( C ) Digestive system: NAT10 regulates hepatic lipid metabolism and has context-dependent functions in gastrointestinal cancers through RNA and protein targets, including p53. ( D ) Urinary system: NAT10-dependent regulation of p21 or NCOA4 contributes to bladder-cancer phenotypes and renal ischemia–reperfusion injury. Arrows indicate activation or increased stability; blunt-ended lines indicate inhibition; upward and downward arrows indicate expression changes Roles of NAT10 in other biological systems. ( A ) Endocrine and metabolic regulation: NAT10-associated ac4C affects transcripts involved in fatty-acid synthesis, uptake, adipogenesis, and ferroptosis. ( B ) Respiratory system: NAT10-mediated ac4C of TGFB1, HMGB1, or TFRC mRNAs has been linked to epithelial-mesenchymal transition, inflammation, mitochondrial dysfunction, and ferroptosis. ( C ) Digestive system: NAT10 regulates hepatic lipid metabolism and has context-dependent functions in gastrointestinal cancers through RNA and protein targets, including p53. ( D ) Urinary system: NAT10-dependent regulation of p21 or NCOA4 contributes to bladder-cancer phenotypes and renal ischemia–reperfusion injury. Arrows indicate activation or increased stability; blunt-ended lines indicate inhibition; upward and downward arrows indicate expression changes In the digestive system, NAT10 has been implicated in digestive tract malignancies, hepatic lipid synthesis and uptake, and pancreatitis. However, the exact role of NAT10 in digestive cancer remains unclear. In gastric cancer, NAT10 has been reported to promote cell proliferation and migration, and may facilitate early metastatic spread of tumor microvascular metastasis (Mo et al. 2025b ). In contrast, in colorectal cancer, NAT10 has been shown to promote p53 activation by acetylating p53 at K120 and MDM2-mediated ubiquitination, thereby inhibiting cell proliferation (Liu et al. 2016 ). Whether NAT10 acts as an oncogene or a tumor suppressor remains to be further investigated. In the liver, NAT10 regulates hepatic lipid metabolism by modulating the stability and/or ac4C modification of transcripts involved in lipogenesis and lipid uptake, including Srebf1, Scap, Srebp-1c, and MEK6 (Bei et al. 2023 ; Yang et al. 2024 ; Li et al. 2025a ). Remodelin treatment was reported to improve hepatic steatosis and dyslipidemia in preclinical models (Yang et al. 2024 ; Wang et al. 2024a ). However, the specificity of Remodelin for NAT10 has been questioned, as it did not reduce NAT10-dependent ac4C in cellular assays and showed no direct binding to the catalytic pocket (Shrimp et al. 2021 ). Therefore, these metabolic effects should be corroborated by direct NAT10 target-engagement assays and orthogonal genetic models before being attributed to NAT10 inhibition. Furthermore, NAT10 has been reported to enhance lipid uptake by stabilizing CD36 and FATP2 mRNAs in an ac4C-dependent manner (Zhang et al. 2024b ). In severe acute pancreatitis, NAT10 exacerbates pancreatic injury by promoting ac4C modification of NLRP3 mRNA, thereby enhancing its expression (Gao et al. 2025 ) (Fig.  8 C). In the respiratory system, NAT10 is primarily involved in the development of respiratory-related tumors and lung injury. In non-small cell lung cancer (NSCLC), c-Myc binds to the NAT10 promoter and upregulate NAT10 expression, thereby promoting cell proliferation and migration (Wang et al. 2022b ). In Pseudomonas aeruginosa-induced acute lung injury, NAT10 enhances the ac4C modification of HMGB1 mRNA, increasing its stability and expression, which exacerbating mitochondrial dysfunction and inflammatory responses in lung epithelial cells (Huang et al. 2025b ). Additionally, NAT10 mediates the ac4C acetylation of transferrin receptor mRNA, promoting ferroptosis and worsening sepsis-induced lung injury (Xing et al. 2024 ). It has also been demonstrated that PM2.5 promotes NAT10 upregulation, stabilizing TGFB1 mRNA and protein, accelerating EMT and pulmonary fibrosis (Shenshen et al. 2023 ) (Fig.  8 B). In the urinary system, NAT10 takes part in urinary tract tumors and organ injury. Notably, the role of NAT10 in bladder cancer appears to be context-dependent: in UMUC3 and T24 cells, it acts as an oncogene, while in J82 and TCCSUP cells, its effects may shift toward tumor suppression under specific molecular conditions. Studies have shown that CLIC3 regulates the spatial conformation of NAT10, modulating its role of bladder cancer progression. In bladder cancer cells with high CLIC3 expression, NAT10 may exert tumor suppressor to inhibit cell growth (Shuai et al. 2024 ). Furthermore, NAT10 mediates the ac4C modification of NCOA4 mRNA, promoting ferroptosis in renal tubular epithelial cells, thereby exacerbating ischemia–reperfusion injury (IRI)-induced acute kidney injury. Pharmacological inhibition or genetic deletion of NAT10 significantly alleviates IRI-induced renal injury (Shen et al. 2024 ) (Fig.  8 D). In the endocrine system, although there is currently no direct evidence linking NAT10 with endocrine glands, recent studies suggest that NAT10 may indirectly influence endocrine function by regulating RNA expression and metabolic pathways. The lncRNA MEK6-AS1 has been reported to enhance MEK6 mRNA stability through NAT10, impacting lipogenesis, fatty acid metabolism, and osteogenic differentiation, thereby providing a potential new target for treating obesity and other endocrine disorders (Li et al. 2025b ). In a pan-cancer analysis, NAT10 stabilizes several genes involved in fatty acid metabolism via ac4C-dependent RNA modification. Notably, NAT10 inhibition reduced total cellular lipids, triglycerides, and cholesterol levels (Dalhat et al. 2022 ). In ovarian cancer, the function of NAT10 is further validated: IGF2BP1 enhances the translation of NAT10 mRNA via an m6A-dependent mechanism, while NAT10, through the ac4C modification of ACOT7 mRNA, increases its stability and translation efficiency. This regulatory pathway modulates fatty acid metabolism in cancer cells and inhibits ferroptosis, thereby promoting tumor progression (Liu et al. 2024f ). These findings provide new molecular targets for cancer treatment and offer potential therapeutic strategies for endocrine-related diseases, such as obesity and metabolic disorders like diabetes (Fig.  8 A). NAT10 has been implicated in diseases affecting the digestive, respiratory, and urinary systems, as well as in metabolic disorders (Xiao et al. 2024a ; Jiao et al. 2025 ). In cancer, NAT10 has most often been reported to promote malignant phenotypes, although its effects vary across cellular contexts. In gastric cancer, NAT10 was reported to increase ac4C enrichment on COL5A1 mRNA, enhance its stability, and promote migration, invasion, and metastasis (Zhang et al. 2021 ). By contrast, a 2016 study found that NAT10 activated the p53 pathway in models with functional p53, including HCT116 cells. NAT10 acetylated p53 at K120, enhanced its transcriptional activity, and promoted MDM2 ubiquitination and degradation, thereby increasing p53 stability and limiting cell proliferation (Liu et al. 2016 ). Subsequent studies reported tumor promoting effects of NAT10 in colorectal cancer through ac4C associated stabilization of KIF23 and FSP1 mRNAs, leading to activation of Wnt/β catenin signaling and suppression of ferroptosis, respectively (Jin et al. 2022 ; Zheng et al. 2022a ). These apparently divergent findings suggest that NAT10 activity may depend on the cellular model, TP53 pathway competence, and the dominant protein or RNA substrate. In J82 and TCCSUP bladder cancer cells, CLIC3 interacted with NAT10 and reduced NAT10 associated ac4C enrichment and stabilization of p21 mRNA, resulting in lower p21 expression and increased cell proliferation (Shuai et al. 2024 ). Potential determinants of this context dependence may include TP53 pathway activity, substrate availability, interacting proteins, and subcellular localization, although their causal contributions remain to be established. PCBP1, PCBP2, and TDP43 have been identified as adaptors within a NAT10 containing mRNA acetylation complex that facilitate mRNA tethering and influence substrate preference. Their roles in determining oncogenic or tumor suppressive phenotypes have not been demonstrated (Jiang et al. 2024 ). In hepatocellular carcinoma cells, an engineered NAT10 deletion mutant lacking nucleolar localization sequences accumulated in the cytoplasm and cell membrane, increased α tubulin acetylation and microtubule stability, and enhanced migration and invasion (Tan et al. 2018 ). These findings support localization dependent functional output but do not directly establish altered access to mRNA substrates. Future studies should use lineage matched models and integrate TP53 genotype and pathway activity, endogenous NAT10 localization, adaptor expression, rescue with wild type and catalytically inactive NAT10, target site mutagenesis, nucleotide resolution ac4C mapping, transcriptomics, and proteomics.

NAT10 belongs to the GCN5-related N-acetyltransferase (GNAT) family and is a nucleolar protein encoded by a gene located on the short arm of human chromosome 11 at band p13. The NAT10 protein has a molecular weight of approximately 116 kDa and consists of 1,025 amino acids (Wang et al. 2024a ). Using single-particle cryo-electron microscopy (cryo-EM), researchers have elucidated the structure of Chaetomium thermophilum NAT10 ( Ct NAT10), revealing a symmetrical, heart-shaped dimer containing conserved functional domains. Structure-based mutagenesis and in vitro analysis have demonstrated that two active site residues and two basic patches are essential for RNA acetylation catalysis. Ct NAT10 and human NAT10 are highly conserved with respect to catalytic mechanisms, active sites, and functional domains (Zhou et al. 2026 ). The molecular architecture of NAT10 contains multiple functional domains that likely contribute to substrate specificity and modification site selection (Han et al. 2025 ). These domains cooperate in RNA binding and catalysis, although the molecular determinants governing recognition of distinct RNA classes and selection of individual modification sites remain incompletely defined (Zhou et al. 2026 ). According to annotations in GeneCards and InterPro, NAT10 contains several predicted functional domains, including DUF1726 (107-201aa), an ATPase/helicase module encompassing DUF699 and a P-loop NTPase fold (282-488aa), a GNAT acetyltransferase domain (528-752aa), and a predicted tRNA-binding domain (771-892aa) (Han et al. 2025 ; Xiao et al. 2024b ). The GNAT domain constitutes the catalytic core responsible for transferring acetyl groups from acetyl-CoA to target cytidines in RNA. The helicase-like region and the acetyltransferase domains are closely associated with the role of NAT10 in RNA acetylation and RNA modification (Han et al. 2025 ). NAT10 promotes nucleolar R-loop resolution through its intrinsic helicase-like activity and DDX21 acetylation at K236 and K573, thereby enhancing DDX21 helicase activity and maintaining genome stability (Su et al. 2024 ). In bacteria, the NAT10-family homolog TmcA functions as a tRNA Met acetyltransferase that catalyzes ac4C modification in tRNA Met ensuring accurate recognition of the AUG start codon during translation initiation. The P-loop NTPase fold is predicted to hydrolyze ATP or GTP, potentially providing energy for conformational changes associated with the acetylation process (Han et al. 2025 ; Sleiman and Dragon 2019 ; Rodrigues et al. 2024 ) (Fig.  1 ). Fig. 1 Domain organization and molecular functions of NAT10. NAT10 comprises 1025 amino acids, featuring DUF1726, DUF699, helicase, GNAT, and tRNA-binding domains. NAT10 transfers an acetyl group from acetyl-CoA to lysine residues on proteins and catalyzes ac4C modification on RNA Domain organization and molecular functions of NAT10. NAT10 comprises 1025 amino acids, featuring DUF1726, DUF699, helicase, GNAT, and tRNA-binding domains. NAT10 transfers an acetyl group from acetyl-CoA to lysine residues on proteins and catalyzes ac4C modification on RNA During embryonic development, NAT10 exhibits tissue-specific expression and is enriched in lymphoid organs, the kidneys, the liver and several regions of the central nervous system, including the cerebellum and cerebral cortex (Xie et al. 2023a ). In normal cells, NAT10 is predominantly localized to the nucleus and nucleolus. In cancer cells, the subcellular localization of NAT10 is frequently altered, with redistribution to the cytoplasm, nucleoplasm, or nuclear membrane. Such relocalization has been associated with tumor initiation and progression and may influence intracellular signaling pathways and gene expression programs (Wang et al. 2024b ). Furthermore, the N-terminal region of NAT10 contains a putative nuclear localization signal (NLS) and a potential nucleolar localization signal (NoLS), which may partially overlap. The C-terminal harbors a coiled-coil domain that mediates protein–protein interactions and may contribute to subcellular targeting in coordination with the NLS/NoLS. The subcellular localization of NAT10 largely depends on its NLS sequence. Deletion of the C-terminal region leads to cytoplasmic accumulation of NAT10 (Sleiman et al. 2019). In hepatocellular carcinoma, two regions (residues 68–75 and 989–1018) have been reported to regulate the nuclear localization of NAT10 and its redistribution to the cytoplasm. This relocalization is associated with a change that leads to microtubule stabilization and enhanced migration and invasion of cancer cells (Tan et al. 2018 ). In colorectal cancer, the subcellular distribution of NAT10 correlates with tumor differentiation status and clinical prognosis. In poorly differentiated tumors associated with a poor prognosis, NAT10 predominantly localizes to the cell membrane. For well-differentiated tumors with a favorable prognosis, NAT10 is primarily distributed in the cytoplasm and nucleus or co-localized in both compartments. Predominantly nuclear or nucleolar NAT10 staining, variably accompanied by cytoplasmic localization, has been observed in clear-cell renal cell carcinoma, breast cancer, and melanoma, whereas hepatocellular carcinoma may exhibit loss of nucleolar localization and increased cytoplasmic or membranous staining; NAT10 overexpression has also been reported in soft-tissue sarcomas (Tan et al. 2018 ; Guerrero Llobet et al. 2022 ; Uhlén et al. 2015 ; Shen et al. 2009 ).

Although the role of NAT10 in various biological processes has been increasingly recognized, the development of small molecule inhibitors targeting NAT10 remains relatively limited. A few studies have reported the screening and validation of NAT10- targeting inhibitors, but no clinically approved drugs have emerged. Among the reported compounds, Remodelin has been widely used as a putative NAT10-directed small molecule and has shown phenotypic activity in several preclinical models. However, its suitability as a NAT10-selective chemical probe remains unresolved. Shrimp et al. characterized Remodelin as a cryptic assay-interference chemotype and observed no reduction in NAT10-dependent cytidine acetylation across orthogonal cellular assays, together with no direct evidence of binding to the NAT10 catalytic pocket (Shrimp et al. 2021 ). In accordance with established chemical-probe principles, target-specific pharmacological attribution requires biochemical potency, cellular target engagement, selectivity profiling, and concordance with orthogonal genetic perturbation (Blagg and Workman 2017 ). Therefore, Remodelin-associated findings should be interpreted as pharmacological observations until they are supported by direct target-engagement assays and NAT10 genetic depletion followed by rescue with wild-type or catalytically inactive NAT10. A chemical biology study characterized Remodelin as a cryptic assay-interference chemotype and found no detectable reduction in NAT10-dependent cytidine acetylation (ac4C) across multiple orthogonal cellular readouts, nor any direct evidence of binding to the NAT10 acetyltransferase active site (Shrimp et al. 2021 ). Moreover, NAT10 may regulate cellular phenotypes through ac4C-independent mechanisms, further complicating mechanism attribution based solely on Remodelin (Ma et al. 2024b ). Therefore, the development of efficient and highly selective small molecule inhibitors targeting NAT10 remains a critical focus of current research. Current strategies for the development of small-molecule NAT10 inhibitors primarily include virtual screening, drug repurposing, and rational design (Fig.  9 ). For example, structure-based screening informed by the predicted interaction between Remodelin and NAT10 has identified several FDA-approved or clinically used compounds, including Fosaprepitant, Leucine, Fludarabine, and Dantrolene, as candidate NAT10-binding molecules. However, their efficacy and selectivity still require further experimental validation (Dalhat et al. 2021 ). Among these candidates, fludarabine has been reported to inhibit NAT10-mediated ac4C modification and the expression of ACOT7 mRNA, effectively suppressing ovarian tumorigenesis (Liu et al. 2024a ). Additionally, Liu et al. identified through virtual screening that Panobinostat binds to the catalytic pocket (G641) of NAT10, significantly inhibiting its ac4C acetyltransferase activity. Panobinostat exhibited antitumor effects against hepatocellular carcinoma (HCC) in both in vitro and in vivo models, with limited toxicity reported in the study, highlighting its promise as a candidate NAT10/ac4C-targeting inhibitor (Liu et al. 2024b ). Zou et al. also discovered through virtual screening that compounds like paliperidone and AG-401 can bind to NAT10, inhibiting its function and significantly suppressing osteosarcoma progression, suggesting these compounds may serve as potential NAT10 inhibitors (Zou et al. 2024 ). Zhang et al. also identified NAT10-2023 as a novel small-molecule NAT10 inhibitor with high binding affinity and functional inhibitory activity, showing strong therapeutic potential in preclinical hepatocellular carcinoma models (Zhang et al. 2025b ). In addition to virtual screening, researchers have also explored new strategies targeting post-translational self-regulation of NAT10. For example, the lysine site K823 on NAT10 can undergo 2-hydroxyisobutyrylation (Khib) to enhance its stability. Researchers found that a lead compound, #7586–3507, could inhibit Khib modification of NAT10 and showed significant efficacy in tumor models (Liao et al. 2023 ). In recent years, PROTACs have emerged as a promising strategy and opened a new avenue for NAT10-directed therapeutic development. The PROTAC degrader NP1192 has been reported to induce NAT10 degradation, suppress hypoxia-adaptive glycolysis, restore CD8 + effector T-cell function, and enhance the efficacy of anti-PD-L1 therapy, underscoring its therapeutic potential in cancer treatment (Ao et al. 2025 ). Biomimetic technologies and sonosensitive nanorobots have emerged as promising drug delivery platforms that can improve biocompatibility, targeting capability, and controllable drug release while reducing off-target toxicity, thereby providing a new strategy for NAT10-targeted therapy. The sonosensitive biomimetic nanorobot targeting NAT10 phase-separated condensates (Sono@NAT10) has been reported to promote macrophage reprogramming from the M2 to the M1 phenotype through the SRSF2/HDAC10 axis, thereby enhancing antitumor immune responses and improving immunotherapeutic efficacy in colorectal cancer (Zhu et al. 2026 ). GNE-493 was identified as a NAT10-binding compound that suppresses gastric cancer progression by targeting NAT10-mediated ac4C modification of HK2, thereby inhibiting aerobic glycolysis and demonstrating efficacy in cisplatin-resistant cells (Wang et al. 2026 ). Similarly, Emodin has been identified as a candidate NAT10-targeting compound that suppresses colon cancer growth by inhibiting NAT10-mediated ac4C modification of PGK1 and the associated glycolytic program (Wei et al. 2025a ). Moreover, some researchers have integrated NAT10 with disease pathogenesis to explore its synergistic effects for drug repurposing. For instance, in periodontitis research, Ropinirole was investigated for its ability to inhibit NAT10-mediated ac4C RNA acetylation and thereby alleviate LPS-induced periodontal inflammation. This research is based on Ropinirole's previously established anti-inflammatory and alveolar bone regeneration effects (Fan et al. 2022 ) and the fact that NAT10 knockdown significantly reduces inflammation factor production (Liao et al. 2024 ). Fig. 9 NAT10 targeted therapeutic strategies. ( A ) Candidate NAT10-targeting compounds are classified according to their reported evidence, including Remodelin with disputed target engagement, computationally predicted candidates, the reported G641-pocket binder panobinostat, and paliperidone/AG-401 identified through virtual screening and preclinical validation. ( B ) Remodelin enhances the antitumor effects of sorafenib, dacarbazine, and cetuximab plus 5-FU by promoting ferroptosis, apoptosis, drug sensitivity, or tumor regression. However, the contribution of direct NAT10 inhibition remains to be established. ( C ) NAT10 inhibition reduces NPM1 acetylation and PD-L1 transcription, thereby limiting tumor immune evasion; combination with anti-CTLA-4 antibody enhances CD4⁺ and CD8⁺ T cell infiltration and activation and suppresses tumor growth. Red and blue arrows indicate increases and decreases, respectively. Ac, protein acetylation NAT10 targeted therapeutic strategies. ( A ) Candidate NAT10-targeting compounds are classified according to their reported evidence, including Remodelin with disputed target engagement, computationally predicted candidates, the reported G641-pocket binder panobinostat, and paliperidone/AG-401 identified through virtual screening and preclinical validation. ( B ) Remodelin enhances the antitumor effects of sorafenib, dacarbazine, and cetuximab plus 5-FU by promoting ferroptosis, apoptosis, drug sensitivity, or tumor regression. However, the contribution of direct NAT10 inhibition remains to be established. ( C ) NAT10 inhibition reduces NPM1 acetylation and PD-L1 transcription, thereby limiting tumor immune evasion; combination with anti-CTLA-4 antibody enhances CD4⁺ and CD8⁺ T cell infiltration and activation and suppresses tumor growth. Red and blue arrows indicate increases and decreases, respectively. Ac, protein acetylation Despite the initial progress in the development of NAT10 inhibitors, further mechanistic investigation and drug optimization are required to achieve clinical application, particularly in terms of drug selectivity, toxicity, and long-term efficacy. Defining the therapeutic window will also be critical for minimizing unintended effects on healthy cells. Future research may place greater emphasis on integrating molecularly targeted therapies and personalized treatment strategies to facilitate the clinical translation of NAT10 inhibitors. Additionally, advances in artificial intelligence (AI) are expected to improve the efficiency and reduce the cost of developing NAT10-targeting agents, particularly through the integration of virtual screening and molecular docking approaches. More advanced generative models are needed to expand the NAT10 virtual screening library, reducing the search space and improving screening efficiency (Zhang et al. 2025c ). For drug discovery and repurposing, MitoReID has achieved an accuracy of 76.32% in identifying FDA-approved drugs, broadening drug applicability and lowering redevelopment costs (Zhang et al. 2025a ). During clinical trials, AI analysis of patient data can optimize trial designs, identify biomarkers and patient characteristics associated with drug response, improve trial success rates, and predict adverse events and drug interactions using real-world data, thus accelerating the drug translation process (Zhang et al. 2025b ). To facilitate comparison of the available pharmacological agents, currently reported NAT10-directed small molecules and related therapeutic modalities are summarized in Table  2 according to their proposed mechanisms, experimental applications, principal findings, and current level of validation. Table 2 Reported NAT10-targeting compounds and degraders Agent Classification Reported application Key findings and required caveats References Remodelin Putative inhibitor; target engagement disputed HGPS, bone remodeling, muscle atrophy, chemotherapy and immunotherapy combinations Reported cellular and animal phenotypes. Orthogonal assays did not show direct NAT10 binding or reduced NAT10-dependent ac4C. Use only with an explicit caveat and genetic validation (Xie et al. 2023a ; Shrimp et al. 2021 ; Yang et al. 2025 ; Wang et al. 2023a ; Larrieu et al. 2014 ; Balmus et al. 2018 ; Mo et al. 2025a ; Li et al. 2024b ; Liu et al. 2025a ) Fosaprepitant; Leucal; Fludarabine; Dantrolene Virtual-screening candidates Repurposing screen Predicted binding only in the cited screen. Direct biochemical inhibition, cellular target engagement, selectivity, and disease efficacy require validation (Dalhat et al. 2021 ) Fludarabine Repurposed candidate Ovarian cancer and ACOT7 pathway Reported reduction of NAT10-associated ac4C and ACOT7 expression. Because fludarabine has established nucleoside-antimetabolite activities, NAT10-specific contribution requires orthogonal validation (Liu et al. 2024c ) Panobinostat Repurposed candidate; reported NAT10 pocket interaction Hepatocellular carcinoma Reported binding near G641, reduced ac4C activity, and antitumor effects. HDAC inhibition is a major established activity and must be separated from NAT10-dependent effects (Liu et al. 2024d ; Lachenmayer et al. 2012 ) Paliperidone Virtual-screening/functional candidate Osteosarcoma Reported NAT10 binding and suppression of ATF4/ASNS-associated progression. Independent biochemical and selectivity data remain limited (Zou et al. 2024 ) AG-401 Virtual-screening/functional candidate Osteosarcoma Reported NAT10 binding and antitumor activity. Direct target engagement, off-target profiling, and PK data require further validation (Zou et al. 2024 ) NAT10-2023 Designed small-molecule candidate Hepatocellular carcinoma Reported high-affinity binding, inhibition of NAT10-associated ac4C, and preclinical activity through SMAD3 mRNA regulation. Independent replication and full pharmacology are needed (Zhang et al. 2025c ) #7586–3507 Indirect NAT10 modulator Cancer metastasis Reported to reduce NAT10 K823 2-hydroxyisobutyrylation and NAT10 stability. It should not be classified as a direct catalytic inhibitor without binding and enzymology data (Liao et al. 2023 ) NP1192 PROTAC degrader Tumor glycolysis and anti-PD-L1 combination Reported NAT10 degradation, suppression of hypoxia-adaptive glycolysis, recovery of CD8 + T-cell function, and synergy with anti-PD-L1. Selectivity, degrader mechanism, PK, tissue exposure, and safety require independent validation (Ao et al. 2025 ) GNE-493 Reported NAT10-binding candidate Gastric cancer and cisplatin resistance Reported suppression of NAT10-mediated HK2 ac4C and glycolysis. The relationship to any known primary pharmacology and the strength of direct target-engagement evidence should be stated (Wang et al. 2026 ) Emodin Reported NAT10-binding candidate Natural-product candidate Colon cancer Reported inhibition of NAT10-mediated PGK1 ac4C and glycolysis. Emodin is pleiotropic, so NAT10 attribution requires direct binding, selectivity, and rescue experiments (Wei et al. 2025a ) Ropinirole Repurposed candidate Periodontitis Reported reduction of NAT10-associated ac4C and inflammatory responses. Dopamine-receptor-dependent and NAT10-dependent effects should be experimentally separated (Liao et al. 2024 ) Compounds were classified according to the type and extent of evidence reported in the original studies. Agents categorized as virtual-screening candidates, repurposed candidates, functional candidates, or natural-product candidates have shown predicted binding, NAT10-associated cellular effects, or activity in disease models; however, their designation as direct and selective NAT10 inhibitors requires further validation. Rigorous target validation should include orthogonal binding or target-occupancy assays, purified-protein enzymatic analyses, NAT10 knockdown or knockout followed by rescue experiments, selectivity and off-target profiling, and pharmacokinetic and safety assessments. Remodelin is included as a historically used NAT10 inhibitor, although subsequent orthogonal studies failed to confirm direct NAT10 binding or inhibition of NAT10-dependent ac4C formation. #7586–3507 is classified as an indirect NAT10 modulator because it regulates NAT10 post-translational modification and protein stability. NP1192 is classified as a NAT10-targeting proteolysis-targeting chimera because it acts by inducing NAT10 degradation. ac4C, N4-acetylcytidine; HGPS, Hutchinson-Gilford progeria syndrome; PK, pharmacokinetics; PROTAC, proteolysis-targeting chimera. Reported NAT10-targeting compounds and degraders Reported NAT10-binding candidate Natural-product candidate Compounds were classified according to the type and extent of evidence reported in the original studies. Agents categorized as virtual-screening candidates, repurposed candidates, functional candidates, or natural-product candidates have shown predicted binding, NAT10-associated cellular effects, or activity in disease models; however, their designation as direct and selective NAT10 inhibitors requires further validation. Rigorous target validation should include orthogonal binding or target-occupancy assays, purified-protein enzymatic analyses, NAT10 knockdown or knockout followed by rescue experiments, selectivity and off-target profiling, and pharmacokinetic and safety assessments. Remodelin is included as a historically used NAT10 inhibitor, although subsequent orthogonal studies failed to confirm direct NAT10 binding or inhibition of NAT10-dependent ac4C formation. #7586–3507 is classified as an indirect NAT10 modulator because it regulates NAT10 post-translational modification and protein stability. NP1192 is classified as a NAT10-targeting proteolysis-targeting chimera because it acts by inducing NAT10 degradation. ac4C, N4-acetylcytidine; HGPS, Hutchinson-Gilford progeria syndrome; PK, pharmacokinetics; PROTAC, proteolysis-targeting chimera. The involvement of NAT10 in tumor metabolism, therapy resistance, and immune evasion provides a rationale for combining NAT10-directed interventions with chemotherapy, targeted therapy, or immune-checkpoint blockade. However, the mechanistic strength of the available evidence varies substantially among studies. Combination effects observed with compounds lacking validated NAT10 target engagement should be interpreted cautiously, whereas approaches based on direct NAT10 degradation or supported by concordant genetic perturbation provide a stronger basis for evaluating NAT10-dependent therapeutic synergy. Preclinical studies suggest that perturbing NAT10 may modify responses to chemotherapy and targeted therapy. In nasopharyngeal carcinoma, genetic or pharmacological suppression of NAT10 enhanced the response to sorafenib through downregulation of SLC7A11 and induction of ferroptosis (Xue et al. 2024 ). Remodelin treatment was also reported to increase melanoma-cell sensitivity to dacarbazine (Wang et al. 2024b ). Moreover, recent research by Zheng et al. further expanded the application of NAT10 combination therapy. They found that EGFR inhibitors significantly enhanced the therapeutic effect of Remodelin in colorectal cancer, proposing a triple therapy of Remodelin, cetuximab, and 5- fluorouracil as a new treatment option for colorectal cancer patients (Zheng et al. 2025 ). In addition to conventional anticancer therapies, immunotherapy has emerged as an important therapeutic strategy in oncology. Immune checkpoint inhibitors are widely regarded as a cornerstone of modern anticancer immunotherapy (O'Donnell et al. 2019 ). Combination of NAT10 inhibitors with immune checkpoint blockade therapy has also shown significant progress. In cervical cancer, the combination of NAT10 inhibitors and anti-PD-1/PD-L1 antibodies significantly enhanced the effect of immune checkpoint blockade therapy by synergistically activating antitumor immune responses and inhibiting tumor growth (Chen et al. 2023 ). Furthermore, the anti-CTLA-4 monoclonal antibody ipilimumab has demonstrated clinical efficacy in the treatment of various tumors. However, its delayed onset of action and treatment-related toxicity may limit its clinical benefit. Studies have shown that Remodelin may help overcome the delayed response of CTLA-4 monoclonal antibodies by enhancing CTLA-4 expression on T cell surfaces, thereby activating the immunosuppressive tumor microenvironment (TME) (Li et al. 2024a ). Research has demonstrated that the combination of NAT10 inhibitors with anti-CTLA-4 therapy exhibited significantly superior results compared to monotherapy (Qin et al. 2024 ). Despite encouraging preclinical findings, NAT10-directed combination therapy remains at an early stage of development. Future studies should prioritize compounds that demonstrate direct target engagement or target degradation, suppression of relevant NAT10-dependent molecular outputs, and concordance with genetic perturbation. The recent development of NAT10-directed PROTAC degraders such as NP1192 supports the feasibility of achieving potent and mechanistically traceable NAT10 targeting (Ao et al. 2025 ). Such better-characterized agents should be prioritized over nonspecific compounds when investigating NAT10-dependent synergy with chemotherapy, targeted therapy, or immune-checkpoint blockade. Nevertheless, the tissue distribution, degradation selectivity, optimal dose and schedule, therapeutic window, potential effects on normal NAT10-dependent physiology, and long-term safety of these agents require systematic evaluation before clinical translation. Domain-specific language models such as PharmBERT may support more informed clinical drug use by extracting structured pharmacokinetic and safety-related information from prescription labels, thereby facilitating the identification of adverse drug reactions and potential drug–drug interactions (ValizadehAslani et al. 2023 ). In the future, NAT10-based multitarget combination strategies are expected to become an important direction in cancer investigation. By integrating precision medicine and biomarker screening, these approaches may further enhance the personalization and efficacy of treatments. Moreover, integrating multi-omics technologies with systematic evaluation of anticancer drug combinations may facilitate the identification of effective combination regimens and support the refinement of cancer dependency maps (Wei et al. 2025b ). NAT10, the sole known writer of ac4C RNA modification, has emerged as a potential therapeutic target in cancer progression and immune evasion. However, its clinical translation remains at an early stage, with available evidence largely limited to preclinical models. To date, there is no clear evidence that NAT10-targeting agents have entered phase II or III clinical trials to establish their therapeutic efficacy or long-term safety (Li et al. 2025a ). Several key challenges continue to impede further development. First, the druggability of NAT10 remains incompletely defined. Remodelin lacks validated cellular target engagement and NAT10 selectivity (Shrimp et al. 2021 ) and Remodelin-associated phenotypes alone cannot establish the pharmacology of a NAT10-directed therapeutic agent. Future translational studies should prioritize compounds with demonstrated biochemical binding, cellular target engagement, inhibition of the relevant NAT10 catalytic output, broad selectivity profiling, concordance with genetic perturbation, and interpretable pharmacokinetic and pharmacodynamic relationships. Second, inadequate tissue targeting and off-target exposure may narrow the therapeutic window and raise safety concerns. Third, low delivery efficiency and poor intracellular accessibility hinder the accurate evaluation of pharmacokinetic/pharmacodynamic (PK/PD) relationships. Pharmacokinetic limitations like low oral bioavailability may further restrict systemic efficacy (Liu et al. 2025c ). Standardized assessments of tissue distribution, target engagement, and pharmacological response will be essential for informing clinical dose selection and translational decision-making (Ao et al. 2025 ).

NAT10, as a multifunctional acetyltransferase, plays a crucial role in the regulation of RNA and protein acetylation, modulating gene expression, protein function, and cellular metabolism under both physiological and pathological conditions. These molecular regulatory functions collectively underpin the broad involvement of NAT10 in multiple physiological systems, including circulatory, immune, reproductive, neurological, and muscular systems. Accordingly, NAT10 is not only a central node in molecular regulatory networks but also an important bridge linking microscopic molecular events with macroscopic physiological functions. Notably, NAT10 exhibits context-dependent dual functionality across different biological systems, contributing to the maintenance of physiological homeostasis while also potentially promoting disease progression. This duality makes NAT10’s function highly context-dependent, with its specific role influenced by multiple factors, such as cell type, microenvironment, and disease state. Therefore, a deeper understanding of NAT10’s molecular regulatory network in specific disease contexts will be essential for its development as a diagnostic marker and therapeutic target. Although the development of small-molecule inhibitors targeting NAT10 is still at an early stage, several candidate compounds have been identified through virtual screening, modulation of upstream regulatory pathways, and disease-oriented drug development strategies. However, the mechanisms of action, pharmacodynamic properties, and safety profiles still require rigorous validation in both experimental and clinical settings. Preclinical studies in selected tumor models suggest that genetic or pharmacological suppression of NAT10 may enhance responses to chemotherapy, targeted therapy, and immune checkpoint blockade. However, findings obtained with Remodelin should remain provisional because direct binding to the NAT10 catalytic site, suppression of cellular ac4C, and selective cellular target engagement have not been demonstrated (Shrimp et al. 2021 ). Future combination studies should prioritize selective NAT10 inhibitors or degraders with verified cellular target engagement and should pair pharmacological experiments with NAT10 depletion, rescue using wild type and catalytically inactive NAT10, and, where feasible, NAT10 variants resistant to compound binding or degradation. Integrating multiomics analyses with orthogonal biochemical, cellular, and genetic validation will help define the disease specific mechanisms of NAT10 and provide a mechanistic foundation for translation. Future work should prioritize selective NAT10 inhibitors and degraders with demonstrated cellular target engagement and rigorous genetic validation. Their combinations with existing therapies should be advanced toward clinical evaluation only after on target activity, tissue exposure, therapeutic window, and long term safety have been established.

Epigenetic and epitranscriptomic mechanisms regulate gene expression without altering the DNA sequence and involve multilayered mechanisms, including DNA and RNA methylation, histone modifications, and non-coding RNA-mediated regulation (Zhou et al. 2026 ; Wu et al. 2024 ). These regulatory layers play crucial roles in gene transcription, RNA splicing, RNA stability, translation, nuclear export, and chromatin organization, broadly influencing cellular phenotypes and both physiological and pathological processes (Chen et al. 2024a ). N4-acetylcytidine (ac4C) is a conserved epitranscriptomic RNA modification that has attracted renewed interest in epitranscriptomic research in recent years. Detected in rRNA, tRNA, and mRNA, ac4C has been reported to influence RNA stability and translation and may also affect RNA structure, thereby potentially contributing to a wide range of disease contexts (Wang et al. 2025a ). Advances in high-performance liquid chromatography (HPLC), liquid chromatography-mass spectrometry (LC–MS) (Zhang et al. 2024a ), ac4C sequencing (ac4C-seq) (Thomas et al. 2019 ), and reduction of ac4C and conversion to thymidine followed by sequencing (RedaC:T-seq) (Sturgill et al. 2022 ) have substantially advanced ac4C research. Additionally, the development of computational prediction tools, such as Caps-ac4C (Yao et al. 2025 ), PACES (Zhao et al. 2019 ), XG-ac4C (Alam et al. 2020 ), and GANSamples-ac4C (Li et al. 2024a ), has further expanded the methodological repertoire for predicting candidate ac4C sites. NAT10 catalyzes the acetylation of the exocyclic N4-amino group of cytidine using acetyl-CoA as the acetyl donor in an ATP-dependent process, thereby generating ac4C (Liu et al. 2024a ; Schiffers and Oberdoerffer 2024 ). ac 4 C has been identified in transfer RNA (tRNA) and ribosomal RNA (rRNA) and reported in messenger RNA (mRNA) (Beiki et al. 2024 ). In these RNA species, ac4C can influence RNA stability, translation efficiency, and other essential functions (Zhang et al. 2024b ). The modification sites, accessory factors, and regulatory patterns of ac4C vary substantially among different RNA species, resulting in diverse functional consequences across RNA classes and even within the same type of RNA. Currently, NAT10 is the only known writer of ac4C in eukaryotic RNA (Yan et al. 2023 ). Compared with canonical acetyltransferases, NAT10 exhibits distinctive structural and functional features. It contains a GNAT-family acetyltransferase domain together with RNA-binding and helicase-associated regions, which cooperate in RNA substrate recognition and cytidine acetylation (Qin et al. 2025 ). NAT10 has also been reported to acetylate several protein substrates, although the physiological relevance and substrate scope of this activity remain less firmly established. A study reported that Sirtuin7 may function as a putative ac4C eraser particularly on rRNA (Xu et al. 2021 ), where it has been described as a putative NAD + -independent RNA ac4C deacetylase, although its substrate specificity and mechanism of action require further validation. Meanwhile, the nucleolar protein NOP58 preferentially binds ac4C-modified snoRNA, regulates its subnuclear localization and pre-rRNA processing, and has been proposed as a candidate ac4C reader (Kudrin et al. 2024 ). In addition to its role in RNA modifications, NAT10 functions as a protein acetyltransferase, catalyzing the acetylation of histones and non-histone proteins to regulate subcellular localization, protein–protein interactions, and protein stability. It plays important roles in biological processes such as cell-cycle progression (Wang et al. 2019 ), DNA repair (Liu et al. 2016 ), and transcriptional regulation (Cai et al. 2017 ). Although its functions in the circulatory (Warwick et al. 2025 ), reproductive (Xie et al. 2023a ), locomotor (Xiao et al. 2024a ), immune (Zhang et al. 2024c ), and nervous systems (Gao et al. 2024 ) are increasingly being recognized, the underlying mechanisms remain incompletely understood. NAT10 inhibitors are still largely at the preclinical stage. Current priorities include structure-guided discovery of direct inhibitors and degraders, rigorous demonstration of cellular target engagement, and systematic evaluation of selectivity, pharmacokinetics, and safety. These approaches have expanded the repertoire of NAT10-targeted drug candidates and provided new opportunities for future therapeutic optimization. Remodelin has been widely used as a putative NAT10-directed compound and has shown potentially beneficial effects in several preclinical models, including in combination with established therapeutic agents (Xie et al. 2023b ; Wu et al. 2018 ). Therefore, these pharmacological observations should be corroborated by NAT10 genetic depletion or rescue with a catalytically inactive mutant before being definitively attributed to NAT10. These limitations emphasize the need for more selective and target-engaged NAT10 inhibitors before Remodelin-based combination strategies can be considered for clinical translation. A deeper understanding of NAT10 biology and its regulatory pathways in physiological systems will facilitate the future development of NAT10-targeted therapeutics. This review summarizes the structural characteristics, subcellular localization, and multifaceted regulatory mechanisms of NAT10. We systematically outline its molecular functions in RNA and protein modification and its biological roles across multiple physiological systems. In addition, we provide an overview of recent advances in NAT10-targeted strategies, discuss the potential of combining NAT10-targeted strategies with existing therapies, and propose possible approaches for optimization, offering theoretical insights and strategic perspectives to facilitate the development of NAT10 as a potential clinical therapeutic target.