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Chinese Medical Journal logoLink to Chinese Medical Journal
. 2026 Jun 24;139(19):2851–2884. doi: 10.1097/CM9.0000000000004169

Mitochondrial quality control in health and disease: Updates 2026

Zhengzhao Liu 1,2, Wenbao Hu 1, Lin Sun 3,✉, Huafeng Liu 1,✉
Editor: Xuehong Zhang
PMCID: PMC13626680  PMID: 42343697

Abstract

Mitochondria are central to cellular energy metabolism, and their functional integrity is essential for maintaining cellular homeostasis and life processes. Mitochondrial quality control (MQC) encompasses a complex network of mechanisms—including mitochondrial biogenesis, mitochondrial dynamics, mitophagy, mitochondrial proteostasis, and mitochondrial-derived vesicles—that collectively preserve the structural and functional balance of mitochondria. Recent studies have revealed that dysregulation of MQC is closely associated with a broad spectrum of diseases, such as neurodegenerative disorders, cardiovascular diseases, kidney diseases, metabolic syndrome, and cancers, highlighting its critical role in pathological processes. Despite significant progress in elucidating the molecular regulation of MQC, many aspects of its complexity and multilayered regulatory mechanisms remain unresolved. This review provides a comprehensive overview of the major molecular pathways involved in MQC and their functional alterations under physiological and pathological conditions. It emphasizes the abnormalities of MQC in various diseases and explores potential therapeutic targets. Moreover, integrating the latest research advances, this article discusses emerging treatment strategies aimed at restoring and optimizing MQC, with the goal of offering theoretical insights and clinical translation avenues for future disease prevention and management.

Keywords: Mitochondria, Mitochondrial quality control, Mitophagy, Mitochondrial dynamics, Neurodegenerative disease, Cardiovascular disease, Kidney disease, Therapeutic strategies

Introduction

Mitochondria, as semi-autonomous organelles within eukaryotic cells, occupy a central role in cellular energy metabolism and physiological regulation. Beyond their well-known function as the primary source of adenosine triphosphate (ATP) generation via oxidative phosphorylation, mitochondria are intricately involved in multiple cellular processes, including metabolic pathway modulation, redox signaling, calcium homeostasis, and apoptosis regulation. This multifaceted functionality enables mitochondria to adapt their bioenergetic and metabolic output in response to the specific demands of different cell types and organs. For instance, in cardiomyocytes, mitochondria sustain continuous and high-level energy production essential for contractile function throughout life, whereas in hepatocytes, they contribute significantly to metabolic regulation and detoxification processes.[1] Moreover, mitochondria exhibit remarkable plasticity in stem cells and immune cells, where they dynamically reprogram their function to accommodate transitions between quiescent and proliferative states, underscoring their critical role in cellular fate decisions and immune responses.[2,3]

The functional versatility of mitochondria is further exemplified by their participation in cellular signaling networks. Notably, the interplay between mitochondria and signaling pathways such as the p38 mitogen-activated protein kinase (MAPK) pathway influences mitochondrial biogenesis, oxidative phosphorylation efficiency, thermogenesis, and iron homeostasis. This crosstalk modulates mitochondrial responses to oxidative stress and apoptotic stimuli, thereby affecting cellular survival and adaptation mechanisms, particularly in pathological contexts such as cancer.[4] Such regulatory interactions highlight mitochondria as pivotal hubs integrating metabolic cues with intracellular signaling to maintain cellular homeostasis.

To preserve their structural integrity and functional competence, mitochondria rely on a sophisticated set of quality control mechanisms collectively termed mitochondrial quality control (MQC). MQC encompasses mitochondrial biogenesis, mitochondrial dynamics remodeling through fusion and fission, selective autophagic degradation of damaged mitochondria (mitophagy), maintenance of mitochondrial protein homeostasis, and formation of mitochondria-derived vesicles (MDVs) [Figure 1].[2,5] These processes operate synergistically to monitor and repair mitochondrial damage or to eliminate dysfunctional mitochondria, thereby preventing the accumulation of deleterious reactive oxygen species (ROS) and maintaining metabolic stability. The dynamic balance of mitochondrial fusion and fission, for example, not only facilitates mitochondrial distribution and turnover but also modulates apoptotic sensitivity and metabolic adaptation.[6,7] Mitophagy acts as a critical quality control pathway by selectively targeting impaired mitochondria for lysosomal degradation, thus safeguarding cellular energy metabolism and preventing pathological states.[7,8]

Figure 1.

Figure 1

Mitochondrial quality control overview. Overview of mitochondrial quality control, including mitochondrial biogenesis, mitochondrial dynamics, mitophagy, mitochondrial-derived vesicles, and mitochondrial proteostasis. HSP60/70: Heat shock protein 60/70; ISR: Integrated stress response; LONP1: Lon protease 1; NRF1/2: Nuclear respiratory factor 1/2; PGC-1ɑ: Peroxisome proliferator-activated receptor gamma coactivator 1-alpha; TFAM: Mitochondrial transcription factor A; UPRmt: Mitochondrial unfolded protein response.

Dysregulation of MQC mechanisms is increasingly recognized as a central contributor to the pathogenesis of a broad spectrum of diseases, including neurodegenerative disorders such as Parkinson’s disease (PD) and Alzheimer’s disease (AD), cardiovascular diseases, metabolic syndromes, chronic kidney diseases, and cancer.[1,9–12] In neurodegeneration, impaired mitophagy and mitochondrial dysfunction lead to neuronal energy deficits and increased oxidative damage, exacerbating disease progression.[13,14] Notably, emerging therapeutic strategies, such as the transplantation of encapsulated mitochondria, have been shown to alleviate dysfunction in models of PD, offering a novel approach to directly restore mitochondrial health.[15] Cardiovascular pathologies, including hypertensive heart disease and heart failure, involve mitochondrial structural abnormalities, disturbed dynamics, and compromised bioenergetics, which impair cardiac function.[16,17] Metabolic diseases such as metabolic dysfunction-associated fatty liver disease (MAFLD) and type 2 diabetes mellitus (T2DM) are characterized by mitochondrial oxidative stress, altered fatty acid β-oxidation, and impaired energy metabolism, highlighting the therapeutic potential of targeting mitochondrial pathways.[10,18,19] Moreover, cancer cells exploit mitochondrial metabolic reprogramming and MQC alterations to support malignant transformation, immune evasion, and therapeutic resistance, positioning mitochondria as promising targets for anticancer strategies.[20,21]

Despite significant advances in elucidating MQC mechanisms and their disease associations, several challenges remain. Current methodologies often rely on in vitro or permeabilized cell models that may not fully recapitulate the complex intracellular milieu and inter-organelle interactions influencing mitochondrial function in vivo.[5,22] The crosstalk between mitochondria and other organelles, such as lipid droplets, peroxisomes, endoplasmic reticulum (ER), and lysosomes, is critical for coordinated metabolic regulation but remains incompletely understood.[23–26] Furthermore, the regulatory networks underlying MQC exhibit tissue-specific and context-dependent variability, complicating the development of unified models and effective therapeutic interventions.[10,11]

This review provides a comprehensive overview from a 2026 perspective, aiming to update the field by focusing on several cutting-edge angles that have rapidly evolved since 2023. First, we highlight the integration of advanced therapeutic pipelines, such as the evolution of high-precision mitochondrial base editors for mitochondrial DNA (mtDNA) correction[27,28] and the application of proteolysis-targeting chimeras (PROTACs) for targeted protein degradation.[29] Second, we discuss how single-organelle and real-time imaging technologies are revealing new dimensions of mitochondrial dynamics, including the direct observation of inter-organelle communication[30,31] and intercellular mitochondrial transfer.[32,33] Third, we explore the application of spatial multi-omics in systematically analyzing the mitochondrial network within tissue microenvironments. Finally, we examine emerging regulatory factors, such as MDVs[33] and peptides, broadening the understanding of mitochondria as signaling hubs. By synthesizing these recent breakthroughs, this review aims to bridge the gap from molecular mechanisms to translational applications, offering insights into next-generation diagnostic, and therapeutic strategies for mitochondrial-related diseases.

Mechanisms of MQC

Mitochondrial biogenesis

Mitochondrial biogenesis is a fundamental cellular process involving the growth and division of pre-existing mitochondria to increase mitochondrial mass and meet cellular energy demands. This process is tightly regulated at multiple levels, including transcriptional activation of nuclear and mitochondrial genes, protein import, and lipid synthesis, ensuring the expansion and functional integrity of the mitochondrial network. The biogenesis of mitochondria is orchestrated through a complex interplay of signaling pathways and transcription factors, prominently featuring the peroxisome proliferator-activated receptor gamma coactivator 1α (PGC-1α), nuclear respiratory factors (NRF1 and NRF2), and mitochondrial transcription factor A (TFAM), which collectively regulate the expression of mtDNA and mitochondrial proteins encoded by both nuclear and mitochondrial genomes [Figure 2].[34,35]

Figure 2.

Figure 2

Regulatory mechanism of mitochondrial biogenesis. Elevated AMP/ATP ratio, NAD+/NADH ratio, and calcium ion levels activate the AMPK, SIRT1, and CaMK signaling pathways, respectively. This leads to upregulation of PGC-1α expression, which subsequently induces the expression of downstream antioxidant proteins NRF1 and NRF2, promoting TFAM transcription. TFAM regulates mitochondrial DNA replication and transcription, thereby facilitating mitochondrial biogenesis. AMP: Adenosine monophosphate; AMPK: AMP-activated protein kinase; ATP: Adenosine triphosphate; CaMK: Calcium/calmodulin-dependent protein kinase; cAMP: Cyclic adenosine monophosphate; CREB: cAMP response element-binding protein; MAPK: Mitogen-activated protein kinase; mtDNA: Mitochondrial DNA; NAD: Nicotinamide adenine dinucleotide; NADH: Nicotinamide adenine dinucleotide (reduced form); NRF: Nuclear respiratory factors; PGC-1ɑ: Peroxisome proliferator-activated receptor gamma coactivator 1α; PKA: Protein kinase A; SIRT1: Sirtuin 1; TFAM: Mitochondrial transcription factor A.

Recent advances have elucidated the molecular machinery responsible for mitochondrial protein import, such as the translocase of the outer membrane (TOM) complex and the carrier translocase of the inner membrane (TIM22) pathway, which facilitate the integration of nuclear-encoded mitochondrial proteins essential for biogenesis.[36] Moreover, the biogenesis process is not limited to protein synthesis but also involves the assembly of mitochondrial ribosomes (mitoribosomes), which are crucial for mitochondrial translation. The biogenesis of mitoribosomes is a highly coordinated event involving nucleus-encoded assembly factors and redox-sensitive components that may act as sensors to regulate mitochondrial translation under stress conditions.[37]

Mitochondrial biogenesis is responsive to various physiological stimuli, including exercise, environmental stress, and developmental signals, enabling cells to adapt their metabolic capacity accordingly. For instance, in skeletal muscle, mitochondrial biogenesis supports the formation of an extensive mitochondrial reticulum that facilitates efficient substrate diffusion and energy production during endurance exercise and other metabolic challenges.[35] The regulation of mitochondrial biogenesis extends to diverse cell types, including neurons, where local biogenesis in peripheral compartments such as axons and synapses has been proposed to meet localized energy demands, suggesting spatial heterogeneity in biogenesis mechanisms.[38]

The signaling pathways governing mitochondrial biogenesis are multifaceted. Activation of PGC-1α is a central event, often modulated by upstream kinases and transcription factors such as CREB, which can be stimulated by pharmacological agents like catalpol and zafirlukast to promote mitochondrial biogenesis and enhance mitochondrial function in disease models.[39,40] Additionally, mitochondrial ROS have been implicated as signaling molecules that regulate mitochondrial biogenesis, as demonstrated in embryonic models where reduction of mitochondrial ROS led to decreased biogenesis via downregulation of NRF2, PGC-1α, and TFAM.[41]

Mitochondrial biogenesis is intricately linked with other MQC processes. Crosstalk between biogenesis and mitophagy ensures the replacement of damaged mitochondria with newly synthesized ones, a balance that is crucial in health and disease.[42] Dysregulation of mitochondrial biogenesis has been associated with various pathologies, including neurodegenerative diseases such as PD and AD, metabolic disorders, inflammatory conditions, and organ-specific diseases such as liver fibrosis and kidney injury.[43,44] For example, in PD models, defects in mitochondrial biogenesis driven by the repression of PGC-1α due to accumulation of the transcriptional repressor Parkin interacting substrate (PARIS) contribute significantly to mitochondrial dysfunction and neuronal loss.[45,46] Similarly, in pulmonary fibrosis and silicosis, impaired biogenesis mediated through the PGC-1α–NRF1–TFAM axis exacerbates disease progression, highlighting the therapeutic potential of targeting biogenesis pathways.[47]

Pharmacological and lifestyle interventions that enhance mitochondrial biogenesis have garnered attention for their therapeutic promise. Exercise is a potent inducer of biogenesis, improving mitochondrial function and systemic metabolism, with transcriptional coactivators such as transcriptional coactivator with PDZ-binding motif (TAZ) linking exercise stimuli to TFAM and biogenesis.[48,49] Natural compounds, including polyphenols and branched-chain amino acids, have also been shown to modulate mitochondrial biogenesis signaling pathways, offering potential non-pharmacological strategies to ameliorate mitochondrial dysfunction in aging and disease.[50,51] Furthermore, emerging mitochondrial therapeutics, including gene therapy, mitochondrial transplantation, and targeted drug delivery systems, aim to restore or enhance mitochondrial biogenesis and overall MQC.[52]

In summary, mitochondrial biogenesis is a highly regulated, dynamic process essential for cellular energy homeostasis and adaptation to physiological and pathological stimuli. Understanding the molecular mechanisms and regulatory networks of mitochondrial biogenesis continues to expand, providing critical insights into its role in health and disease and uncovering novel avenues for therapeutic intervention targeting MQC.

Mitochondrial dynamics (fusion and fission)

Mitochondrial dynamics are fundamental to maintaining mitochondrial and cellular homeostasis by regulating mitochondrial morphology, distribution, and function. Fusion involves the merging of mitochondrial membranes, allowing content mixing, including mtDNA, proteins, and metabolites, which supports mitochondrial function and integrity. Key mediators of fusion include mitofusin 1 and 2 (MFN1, MFN2) on the outer mitochondrial membrane and optic atrophy 1 (OPA1) on the inner membrane. Conversely, fission results in mitochondrial division, facilitating MQC by segregating damaged mitochondria for degradation and enabling mitochondrial distribution during cell division. Dynamin-related protein 1 (DRP1) is the principal fission protein, recruited to mitochondria by receptors such as mitochondrial fission protein 1 (FIS1), mitochondrial fission factor (MFF), and mitochondrial dynamics protein (MID) 49/51. The balance between these opposing processes is tightly regulated and critical for cellular adaptation to metabolic demands and stress responses [Figure 3].[53–55]

Figure 3.

Figure 3

Schematic illustration of mitochondrial dynamics regulation. A membrane structure derived from the ER forms an constriction site. The DRP1 protein is recruited to mediate mitochondrial fission. Mitochondrial fusion is respectively mediated by MFN1/2 on the OMM and Opa1 on the IMM, coordinating the fusion of the outer and IMMs. DRP1: Dynamin-related protein 1; ER: Endoplasmic reticulum; Fis1: Mitochondrial fission 1 protein; IMM: Inner mitochondrial membrane; Mff: Mitochondrial fission factor; Mfn: Mitofusin; Mid: Mitochondrial dynamics protein; OMM: Outer mitochondrial membrane; Opa1: Optic atrophy 1.

Mitochondrial fusion and fission are dynamically coordinated processes that influence mitochondrial morphology from fragmented to highly interconnected networks. This dynamic remodeling is essential for maintaining mtDNA integrity, optimal bioenergetics, and ROS homeostasis. Studies in yeast models have demonstrated that balanced but reduced rates of fusion and fission are sufficient to preserve mtDNA integrity and mitochondrial function, underscoring the importance of equilibrium rather than absolute activity levels of these processes.[56,57] Post-translational modifications, particularly protein acetylation, have emerged as key regulatory mechanisms modulating the activity of fusion and fission proteins. For example, acetylation promotes mitochondrial fission, while deacetylation enhances fusion, with sirtuin family deacetylases playing pivotal roles in this regulation, thereby linking mitochondrial dynamics to cellular metabolic states.[58,59]

The interplay between fusion and fission extends beyond morphology to influence cellular fate decisions, including apoptosis, proliferation, and differentiation. In mesenchymal stem cells (MSCs), mitochondrial dynamics are instrumental in fate determination, with aberrant fusion or fission leading to dysfunction and impaired regenerative capacity. Similarly, in various pathological contexts such as cancer, neurodegenerative diseases, and metabolic disorders, dysregulation of mitochondrial dynamics contributes to disease progression. For instance, in colorectal cancer, enhanced mitochondrial fission promotes metabolic reprogramming that supports tumor proliferation, invasion, and chemoresistance, whereas moderate fusion can protect cells from oxidative stress-induced damage. This dual role highlights the complexity of targeting mitochondrial dynamics therapeutically.[60–62]

In neurodegenerative diseases, mutations affecting fusion and fission proteins (e.g., MFN2, OPA1, and DRP1) disrupt mitochondrial morphology and function, contributing to neuronal loss and disease progression. Therapeutic strategies aiming to restore mitochondrial dynamics, such as antisense oligonucleotide-mediated silencing of fission factors or pharmacological modulation of fusion proteins, have shown promise in rescuing mitochondrial dysfunction in disease models. Moreover, mitochondrial dynamics are intricately linked with calcium signaling and inter-organelle communication, particularly at mitochondria-associated membranes (MAMs), further influencing neuronal health.[63–65]

Recent studies have also uncovered novel regulatory proteins that bridge fusion and fission machineries, such as mitochondrial elongation factors (MIEF1 and MIEF2), which interact with both fusion proteins (MFN1/2) and fission components (DRP1), suggesting a coordinated mechanism for balancing mitochondrial morphology. This crosstalk adds an additional layer of complexity to the regulation of mitochondrial dynamics and presents new targets for therapeutic intervention.[66] Furthermore, mitochondrial dynamics influence immune responses, as modulation of fusion and fission in endothelial cells can alter immunogenicity and T-cell activation, with implications for transplant biology and inflammatory diseases.[67,68] In rheumatoid arthritis (RA), mitochondrial dysfunction is a primary driver of inflammation by activating the NOD-like receptor thermal protein domain associated protein 3 (NLRP3) inflammasome, which leads to the release of proinflammatory cytokines such as IL-1β and pyroptosis.[69] Furthermore, mitochondrial dysregulation critically promotes macrophage polarization towards the pro-inflammatory M1 phenotype.[70] Targeting this mitochondria-NLRP3/macrophage axis with Osthole that restores mitochondrial homeostasis represents a promising therapeutic strategy to suppress inflammation and bone destruction.[71,72]

In summary, mitochondrial fusion and fission are vital, interdependent processes that maintain MQC, adapt mitochondrial function to cellular needs, and influence cell fate. Dysregulation of these dynamics is implicated in a wide spectrum of diseases, including cancer, neurodegenerative disease, metabolic disorders, and immune-mediated conditions. Advances in understanding the molecular mechanisms governing fusion and fission, including post-translational modifications and novel regulatory proteins, are driving the development of targeted therapies aimed at restoring mitochondrial homeostasis and improving disease outcomes.[54,67,73]

Mitophagy

Mitophagy, a specialized form of macroautophagy, is a crucial MQC mechanism that selectively degrades damaged or dysfunctional mitochondria to maintain cellular homeostasis. This process is essential for preserving mitochondrial integrity and function, particularly in energy-demanding cells such as neurons and cardiomyocytes. The molecular mechanisms of mitophagy involve multiple pathways, including the well-characterized ubiquitin-dependent pathway and ubiquitin-independent pathways. Upon mitochondrial damage, PTEN-induced putative kinase 1 (PINK1) accumulates on the outer mitochondrial membrane, recruiting and activating parkin RBR E3 ubiquitin protein ligase (PRKN), an E3 ubiquitin ligase, which ubiquitinates mitochondrial surface proteins to signal for autophagic degradation. However, recent studies have revealed that mitophagy can also proceed via ubiquitin-independent pathways, highlighting the complexity and redundancy of MQC systems [Figure 4].[74–76]

Figure 4.

Figure 4

Mechanism of mitophagy. AMPK activates the ULK complex, which subsequently recruits and activates the class III PI3K (VPS34) complex. PI3P promotes the initiation of the autophagic membrane and facilitates LC3 lipidation, thereby driving autophagosome formation. Mitophagy is broadly classified into ubiquitin-dependent and ubiquitin-independent pathways, mediated by distinct autophagy receptors: Ubiquitin-dependent mitophagy relies on receptors such as OPTN, NDP52, SQSTM1, NBR1, TAX1BP1, and TOLLIP, which recognize ubiquitinated proteins on the outer mitochondrial membrane. Ubiquitin-independent mitophagy is mediated by integral outer mitochondrial membrane proteins (e.g., NIX, BNIP3, FUNDC1, and FKBP8) that directly bind LC3 on the autophagosome membrane. Damaged mitochondria are encapsulated by the autophagosome to form a mitophagosome, which fuses with lysosomes for degradation and clearance. AKT: Protein kinase B; AMBRA1: Autophagy and beclin-1 regulator 1; ATG: Autophagy-related gene; BNIP1: BCL2 interacting protein 1; BECN1: Beclin 1; FIP200: Focal adhesion kinase family interacting protein of 200 kDa; FKBP8: FK506 binding protein 8; FUNDC1: FUN14 domain containing 1; LC3: Light chain 3; mTOR: Mammalian target of rapamycin; NBR1: Neighbor of BRCA1 gene 1; NDP52: Nuclear dot protein 52; NIX: NIP3-like protein X; OPTN: Optineurin; PI: Phosphatidylinositol; PI3K I: Phosphoinositide 3-kinase class I; PI3K III: Phosphoinositide 3-kinase class III; PI3P: Phosphatidylinositol 3-phosphate; PINK1: PTEN-induced putative kinase 1; PIP2: Phosphatidylinositol 4,5-bisphosphate; PIP3: Phosphatidylinositol 3,4,5-trisphosphate; PRKN: Parkin RBR E3 ubiquitin protein ligase; SQSTM1: Sequestosome 1; TAX1BP1: Tax1 binding protein 1; TOLLIP: Toll interacting protein; Ub: Ubiquitin; ULK1: Unc-51 like autophagy activating kinase 1; UVRAG: UV radiation resistance associated gene.

Mitophagy plays a pivotal role in various physiological and pathological contexts. In cardiac tissue, mitophagy is essential for removing dysfunctional mitochondria that accumulate during ischemic stress and aging, thereby protecting cardiomyocytes from oxidative damage and apoptosis. For instance, activation of mitophagy has been shown to alleviate ischemia/reperfusion-induced microvascular damage by improving MQC, reducing oxidative stress, and sustaining endothelial cell viability and proliferation.[77,78] Conversely, defective mitophagy contributes to cardiac frailty and heart failure by allowing the accumulation of damaged mitochondria, which exacerbate ROS production and mitochondrial dysfunction.[79,80] The interplay between mitophagy, mitochondrial dynamics (fusion and fission), and the ubiquitin-proteasome system (UPS) further modulates mitochondrial quality, with mitochondrial fission facilitating the segregation of damaged mitochondria destined for degradation.[81,82]

In the nervous system, mitophagy is critical for neuronal health and survival. Neurons, due to their high energy demands and complex morphology, rely heavily on efficient mitochondrial turnover. Impairments in mitophagy are implicated in the pathogenesis of neurodegenerative diseases such as PD, Alzheimer’s disease (AD), Huntington’s disease (HD), and amyotrophic lateral sclerosis (ALS). Mutations in PINK1 and PRKN genes cause familial forms of PD by disrupting mitophagy, leading to the accumulation of dysfunctional mitochondria and neuronal death.[74,83,84] Moreover, mitophagy dysfunction is associated with defective mitochondrial clearance and increased oxidative stress in AD and other neurodegenerative disorders, highlighting mitophagy as a promising therapeutic target.[85–87] Emerging evidence also suggests that mitophagy intersects with other cellular processes, such as inflammation, with mitophagy modulating inflammasome activation and thereby influencing immune responses and disease progression.[88]

Mitophagy is not only involved in disease but also in physiological adaptations and aging. For example, mitophagy contributes to mitochondrial proteome remodeling during differentiation and metabolic shifts, and its efficiency declines with age, contributing to age-related pathologies.[89,90] Pharmacological and lifestyle interventions, including exercise and ketogenic diets, have been shown to enhance mitophagy, improving mitochondrial quality and cellular health.[91,92] Furthermore, novel biochemical approaches, such as chimeric autophagy-tethering compounds (ATTECs), have been developed to selectively induce mitophagy, offering potential therapeutic strategies for diseases characterized by mitochondrial dysfunction.[93]

In various organ systems, mitophagy maintains mitochondrial homeostasis under stress conditions. In the liver, mitophagy protects against ischemia/reperfusion injury (IRI) and metabolic diseases by removing damaged mitochondria and regulating mitochondrial biogenesis.[94,95] In skeletal muscle, mitophagy contributes to muscle mass maintenance and function, with impaired mitophagy linked to sarcopenia and obesity-related muscle decline; interventions enhancing mitophagy can mitigate these effects.[96,97] In renal diseases, the accumulation of dysfunctional mitochondria contributes to inflammation and fibrosis, driving disease progression.[98,99] Natural compounds (e.g., Honokiol and Sulforaphane) and traditional Chinese medicine Tongluo Yishen decoction ameliorated mitochondrial dysfunction and fibrosis by regulating oxidative stress and PINK1/PRKN-mediated mitophagy.[100–102] These findings provide preclinical evidence that modulating specific mitophagy pathways can mitigate both acute and chronic renal damage. Additionally, mitophagy modulates mitochondrial quality in response to environmental toxins and pharmacological agents, as seen in studies involving cadmium, zinc oxide nanoparticles, and chloroquine, where mitophagy dysregulation contributes to cellular toxicity.[103–105]

At the molecular level, mitophagy is tightly regulated by signaling pathways involving sirtuins, AMP-activated protein kinase (AMPK), mammalian target of rapamycin (mTOR), and transcription factors such as PGC-1α, forkhead box O (FOXO), and transcription factor EB (TFEB), which coordinate mitochondrial biogenesis, autophagy, and lysosomal function.[92,106,107] Crosstalk between mitophagy and mitochondrial dynamics ensures the selective removal of damaged mitochondria while maintaining the mitochondrial network. Moreover, alternative mitophagy pathways, such as Rab9-dependent autophagy, have been identified, expanding the understanding of MQC mechanisms.[108,109]

Mitochondrial proteostasis

Mitochondrial proteostasis is a critical process that encompasses the synthesis, import, folding, assembly, and degradation of mitochondrial proteins to maintain mitochondrial function and cellular health. Given that the majority of mitochondrial proteins are nuclear-encoded and synthesized in the cytosol, efficient and tightly regulated import mechanisms are essential to deliver these precursors into mitochondria, where they undergo folding and maturation. Disruptions in these processes lead to proteotoxic stress within mitochondria, triggering a cascade of quality control responses to restore homeostasis or initiate organelle degradation if damage is irreparable. The mitochondrial proteostasis network includes molecular chaperones such as mitochondrial heat shock protein 70 (mtHSP70) and mtHSP60, proteases such as lon protease 1 (LONP1) and caseinolytic mitochondrial matrix peptidase proteolytic subunit (CLPP), and the UPS that surveils mitochondrial outer membrane proteins and import channels. For example, LONP1 cooperates with mtHSP70 to promote protein folding and prevent aggregation of mitochondrial matrix proteins, with its ATPase activity critical for this chaperone-like function [Figure 5].[110–112] The mitochondrial unfolded protein response (UPRmt) is a key signaling pathway activated upon accumulation of unfolded or misfolded proteins, leading to transcriptional upregulation of chaperones and proteases to mitigate proteotoxic stress.[113–115] Notably, UPRmt activation is context-dependent and can be protective or deleterious depending on the physiological or pathological state.[116–118]

Figure 5.

Figure 5

Schematic drawing depicting mitochondrial proteostasis. On one hand, the ISR activates downstream ATF4 through phosphorylation of eIF2α. On the other hand, the accumulation of unfolded proteins in mitochondria triggers the initiation of the UPRmt, leading to the activation of ATF4, ATF5, and CHOP. These transcription factors translocate into the nucleus to regulate the transcription of mitochondrial-related proteases (e.g., LONP1, ClpP), chaperones (e.g., HSP60, HSP70), and antioxidant enzymes. The newly synthesized proteins subsequently enter the mitochondria, where they facilitate proper protein folding, degrade misfolded proteins, and eliminate reactive oxygen species, thereby maintaining mitochondrial proteostasis. ATF4: Activating transcription factor 4; ATF5: Activating transcription factor 5; BRG1: Brahma-related gene 1; CAT: Catalase; CHOP: C/EBP homologous protein; ClpP: Caseinolytic mitochondrial matrix peptidase proteolytic subunit; DELE1: DAP3-binding cell death enhancer 1; eIF2a: Eukaryotic initiation factor 2 alpha; ERɑ: Estrogen receptor alpha; FOXO3: Forkhead box O3; GCN2: General control nonderepressible 2; HRI: Heme-regulated inhibitor; HSF1: Heat shock factor 1; HSP10: Heat shock protein 10; HSP60: Heat shock protein 60; HSP70: Heat shock protein 70; HTRA2: HtrA serine peptidase 2; ISR: Integrated stress response; LONP1: Lon protease 1; NRF1: Nuclear respiratory factor 1; PERK: Protein kinase R-like endoplasmic reticulum kinase; PKB: Protein kinase B (AKT); PKR: Protein kinase R; SIRT3: Sirtuin 3; SOD2: Superoxide dismutase 2; SSBP1: Single-stranded DNA-binding protein 1; TIM: Translocase of the inner membrane; TOM: Translocase of the outer membrane; UPRmt: Mitochondrial unfolded protein response.

Mitochondrial protein import quality control is another crucial aspect of proteostasis. TOM complex serves as the entry gate for most precursor proteins, and its function is closely monitored to prevent clogging by misfolded or stalled precursors. Defective import leads to accumulation of precursor proteins in the cytosol or mitochondrial intermembrane space, eliciting stress responses such as the integrated stress response (ISR) and proteasomal degradation pathways.[119–121] Post-translational modifications, such as SUMOylation of TOM40, regulate the assembly and function of the import machinery, with dysregulation implicated in neurodegenerative diseases such as AD.[122] Furthermore, mitochondrial proteostasis is interconnected with cellular proteostasis networks, as mitochondrial import defects can cause cytosolic aggregation of mitochondrial precursor proteins and exacerbate proteotoxicity.[123,124]

Mitochondrial proteases and chaperones not only maintain protein quality but also regulate mitochondrial dynamics, bioenergetics, and lipid metabolism. For instance, the m-ATPases associated with diverse cellular activities (AAA) protease yeast mitochondrial escape 1 (Yme1) modulates protein import via TIM22 and TIM23 pathways, respiratory chain complex function, and mitochondrial lipid biosynthesis, thereby influencing mitochondrial plasticity.[111] The mitochondrial chaperone code, governed by post-translational modifications, fine-tunes chaperone activity and mitochondrial proteostasis, with implications for disease states.[125] In addition, small mitochondrial proteins such as neighbor of E-R Channel LINk (NERCLIN) regulate cardiolipin homeostasis and mitochondrial ultrastructure, linking lipid metabolism to proteostasis.[126]

Mitochondrial proteostasis dysfunction is implicated in a spectrum of diseases, including cardiomyopathies, neurodegenerative disorders, metabolic syndromes, and cancer. Mutations in genes encoding mitochondrial chaperones, proteases, and import machinery components cause mitochondrial cardiomyopathies and skeletal phenotypes, highlighting the clinical relevance of proteostasis maintenance.[127,128] In neurodegeneration, impaired mitochondrial proteostasis exacerbates proteinopathies by disrupting bioenergetics and mitophagy, contributing to disease progression.[129,130] In metabolic diseases such as type 2 diabetes and nonalcoholic fatty liver disease, dysregulated mitochondrial proteostasis leads to mitochondrial dysfunction and cellular stress, with therapeutic potential in targeting proteostasis pathways.[112,131] Moreover, mitochondrial proteostasis influences aging and longevity, as interventions restoring proteostasis can improve muscle function and extend lifespan.[132,133]

In summary, mitochondrial proteostasis is a multifaceted and dynamic process essential for mitochondrial and cellular function. It integrates protein import, folding, degradation, and stress signaling pathways to preserve mitochondrial integrity. The failure of these mechanisms underlies a broad range of pathologies, making mitochondrial proteostasis a critical focus for understanding disease mechanisms and developing therapeutic strategies.[5,134,135]

Mitochondria-derived vesicles

MDVs represent a critical and evolutionarily conserved MQC mechanism that complements other well-known processes such as mitophagy, fusion/fission dynamics, and mitochondrial biogenesis. MDVs are small vesicles, typically ranging from 70 to 150 nm in diameter, that bud off from mitochondria under physiological conditions or in response to mild oxidative stress, selectively packaging damaged or oxidized mitochondrial proteins and lipids for degradation in lysosomes or peroxisomes [Figure 6]. This selective removal of damaged mitochondrial components via MDVs preserves mitochondrial structural and functional integrity and helps restore cellular homeostasis without necessitating the wholesale degradation of entire mitochondria.[136,137] The biogenesis of MDVs involves complex molecular machinery, including sorting nexins such as sorting nexin 9 (SNX9), which is regulated by post-translational modifications such as lysine β-hydroxybutyrylation driven by metabolites such as β-hydroxybutyrate (BHB). This modification enhances SNX9 interaction with inner mitochondrial membrane (IMM) and matrix proteins, promoting the formation of IMM/matrix MDVs and thereby improving mitochondrial function.[138–140] In addition, mitochondrial dynamics proteins such as DRP1, along with MIRO1/2 and MID49/51, orchestrate MDV formation through membrane protrusion and scission processes, highlighting the involvement of mitochondrial fission machinery in MDVs biogenesis.[141]

Figure 6.

Figure 6

Schematic diagram of MDVs. Mitochondria maintain functional homeostasis by generating vesicles encapsulated by either double or single membranes. RAB7/9+ double-membrane vesicles mediate the delivery of mitochondrial antigens to the cell surface for immune presentation. PDH+ double-membrane vesicles and TOMM20+ single-membrane vesicles enter the MVB pathway. These subsequently fuse with lysosomes for microautophagic degradation or with the plasma membrane for exocytic release as exosomes. MAPL+ single-membrane vesicles target peroxisomes for degradation. This diversified vesicular trafficking system enables mitochondria to regulate quality control, metabolic coordination, and interorganellar communication. DRP1: Dynamin-related protein 1; EV: Extracellular vesicle; MAPL: Mitochondrial-anchored protein ligase; MDV: Mitochondrial-derived vesicle; MHC-I: Major histocompatibility complex class I; MVB: Multivesicular body; OPA1: Optic atrophy 1; PDH: Pyruvate dehydrogenase; RAB7/9: Ras-associated binding protein 7/9; SNX9: Sorting nexin 9; TOMM20: Translocase of outer mitochondrial membrane 20.

MDVs serve multiple biological functions beyond quality control. They facilitate inter-organelle communication, notably between mitochondria and lysosomes or peroxisomes, and contribute to peroxisome de novo biogenesis. MDVs also participate in immune modulation by mediating mitochondrial antigen presentation and limiting the release of mitochondrial damage-associated molecular patterns (DAMPs), thereby modulating inflammatory responses.[136,142] The trafficking of MDVs to lysosomes is tightly regulated by adaptor proteins such as toll interacting protein (TOLLIP), which coordinates PRKN-dependent endosomal sorting of MDVs, ensuring efficient delivery and degradation of damaged mitochondrial cargo.[143] This pathway is distinct from canonical mitophagy and can act as a first line of defense against oxidative stress by selectively removing mitochondrial components before mitophagy is triggered.[137] In pathological contexts, dysregulation of MDV formation or trafficking has been implicated in neurodegenerative diseases, cardiovascular diseases, and cancer. For example, enhanced MDV production has been observed in autophagy-deficient cancer cells as a compensatory mechanism to maintain mitochondrial homeostasis.[109,144] Moreover, MDVs have been linked to protection against hypoxic injury in cardiomyocytes by inhibiting mitochondrial apoptosis via B-cell lymphoma 2 (Bcl-2)-containing MDVs, suggesting therapeutic potential in ischemic heart disease.[145,146]

Emerging evidence also suggests that MDVs contribute to the formation of extracellular vesicles (EVs) containing mitochondrial components, which play roles in intercellular communication and systemic signaling. These mitochondrial extracellular vesicles (mitoEVs) can transfer mtDNA, proteins, and even intact mitochondria between cells, influencing recipient cell metabolism, immune responses, and tissue regeneration.[147,148] The heterogeneity of MDVs and mitoEVs, including subtypes such as mitovesicles, mitophers, and mitolysosomes, underscores their diverse physiological and pathological roles. For instance, platelet-derived EVs containing mitochondria modulate neutrophil function and inflammatory responses, highlighting the immunomodulatory capacity of mitochondrial cargo transfer.[149] Furthermore, metabolic regulation of MDV biogenesis by metabolites such as BHB links cellular metabolic status to MQC, providing a mechanistic basis for metabolic interventions in mitochondrial dysfunction.[138,139]

Despite these advances, several aspects of MDV biology remain incompletely understood. The precise molecular signals dictating cargo selection, the full spectrum of MDV subtypes, and their distinct trafficking routes require further elucidation. Moreover, the interplay between MDVs and other MQC pathways, such as mitophagy and UPRmt, and their collective impact on cellular homeostasis and aging are active areas of investigation.[114,150] Understanding the regulatory networks governing MDVs formation and function holds promise for developing novel diagnostic biomarkers and therapeutic strategies targeting mitochondrial dysfunction in a range of diseases including neurodegeneration, cardiovascular disorders, and metabolic syndromes.[151,152] In summary, MDVs are versatile MQC entities that maintain mitochondrial and cellular health by selectively removing damaged components, mediating organelle crosstalk, and facilitating intercellular communication, thereby representing a critical frontier in mitochondrial biology and disease therapeutics.

Nuclear–mitochondria crosstalk in genome maintenance and signaling

Nuclear–mitochondrial crosstalk is central to coordinating mitochondrial genome (mtDNA) stability and cellular fate.[153] This interaction is achieved through multi-layered mechanisms, including mitochondrial targeting of nuclear-encoded proteins, transmission of stress signals, and epigenetic regulation.

The specific import of nuclear-encoded DNA repair proteins into mitochondria constitutes the first line of defense for maintaining mtDNA integrity. For instance, the base excision repair (BER) pathway, crucial for clearing oxidative damage to mtDNA, relies on a full set of enzymes encoded by the nuclear genome and transported to the mitochondria.[154] Defects in this nuclear-encoded, mitochondrial-targeted repair system led to accumulation of mtDNA damage, dysfunction of the electron transport chain, and a vicious cycle of elevated ROS. This is particularly prominent in metabolically active cells like neurons and is closely associated with neurodegenerative diseases.[155,156] Furthermore, TFAM is not only essential for mtDNA packaging and transcription but also critical for maintaining mtDNA stability and integrity.[157]

When mitochondrial function is compromised, cells initiate signaling pathways such as the ISR for communication and adaptation. For example, in non-tuberculous mycobacterial (NTM) infection, impaired mitochondrial function in macrophages is linked to attenuated expression of peroxisome PGC-1α and TFAM. Restoring their expression can remodel mitochondrial function and enhance immune response.[158] This reveals a mechanism by which nuclear factors sense mitochondrial status to globally regulate cellular metabolism and defense.

In recent years, mitochondria-derived peptides (MDPs) have emerged as a novel class of signaling molecules, adding a new dimension to nuclear-mitochondrial dialog. These small peptides encoded by mtDNA (e.g., Humanin[159] and mitochondrial open reading frame (ORF) of the 12S ribosomal RNA (rRNA) type-c [MOTS-c][160]) can be released into the cytoplasm or extracellular space, influencing nuclear gene expression networks related to metabolism, stress response, and aging. Although not directly explored in the current retrieved literature, they represent a significant emerging research direction in this field.

Genetic and epigenetic mechanisms work together to finely regulate this interactive network. At the genetic level, mutations in nuclear genes encoding MQC proteins can directly disrupt mtDNA stability. For instance, specific mtDNA mutations and haplotype polymorphisms are closely associated with metabolic reprogramming and malignant progression in thyroid cancer.[161,162] At the epigenetic level, chemical modifications of mtDNA itself (e.g., methylation) and epigenetic regulation of nuclear MQC genes play crucial roles. In diabetic retinopathy, hyperglycemia leads to DNA hypermethylation of the mtDNA-encoded long non-coding RNA CytB (LncCytB). Its downregulated expression subsequently impairs mitochondrial genomic stability and function, a process that can be reversed by DNA methyltransferase inhibitors.[163] This clearly defines the direct role of epigenetic dysregulation in linking metabolic disorders to mitochondrial dysfunction. Concurrently, methylation of nuclear DNA or histone modifications may regulate the expression of nuclear genes involved in MQC, such as BER enzymes and TFAM, thereby indirectly affecting mitochondrial homeostasis.

In summary, the nucleus and mitochondria form a dynamic, integrated regulatory network through protein translocation, signal transduction, and epigenetic programming. Dysregulation of this network, whether due to genetic mutations or epigenetic alterations, disrupts mtDNA stability and drives various pathological processes, including cancer,[164,165] neurodegenerative diseases,[155,156] and complications of metabolic diseases.[166,167] A deeper understanding of this interaction mechanism will provide new strategies for treating related diseases by restoring nuclear-mitochondrial communication.

Other important mechanisms regulating mitochondrial function

Beyond the classical pathways of MQC, a multitude of additional mechanisms intricately regulate mitochondrial function to maintain cellular homeostasis and respond to physiological and pathological stimuli. One critical layer of regulation involves the modulation of mitochondrial dynamics and morphology by protein complexes such as the BBSome, which controls mitochondrial fission through regulation of DRP1 phosphorylation and localization. Disruption of the BBSome leads to mitochondrial hyperfusion and impaired mitochondrial respiration, highlighting the importance of precise control over mitochondrial morphology for optimal function.[168] Similarly, MFN2 plays a pivotal role not only in mitochondrial fusion but also in maintaining MAMs between mitochondria and the ER. MFN2 deficiency disrupts MAM integrity, leading to mitochondrial fragmentation, impaired calcium homeostasis, and activation of ER stress responses, which collectively contribute to pathological remodeling such as cardiac dysfunction and neurodegeneration.[169,170] The MAMs themselves serve as crucial hubs for inter-organelle communication, regulating lipid and ion transfer, signaling pathways, and mitochondrial dynamics. Proteins such as mitochondrial LONP1 have been identified as novel MAM tethers that coordinate MAM integrity and mitochondrial function, with their deficiency causing mitochondrial fragmentation and metabolic reprogramming.[171]

Mitochondrial function is also modulated by the interaction with other cellular components, such as the cytoskeleton and plasma membrane. For instance, palmitoylated cytoskeleton-associated protein 4 (CKAP4) binds to mitochondrial porin voltage-dependent anion-selective channel protein 2 (VDAC2) at ER-mitochondria contact sites, regulating mitochondrial calcium uptake and membrane potential, thereby influencing oxidative phosphorylation and cellular proliferation.[172]

At the molecular level, mitochondrial protein homeostasis is maintained by a network of chaperones, proteases, and ubiquitin-dependent degradation pathways. The mitochondrial protein import machinery acts as a sentinel for mitochondrial function, with impaired import triggering quality control responses including mitochondrial-associated degradation (MAD) and crosstalk with ER-associated degradation (ERAD) systems. These pathways ensure the removal of misfolded or mislocalized proteins, preserving mitochondrial proteome integrity and function.[5,120,173] In addition, mitochondrial RNA quality control mechanisms, mediated by pentatricopeptide repeat (PPR) proteins, regulate mitochondrial transcript processing, editing, and decay, which are essential for proper mitochondrial gene expression and function.[174]

Mitochondrial function is further influenced by signaling pathways involving mitochondrial receptors for hormones and intracellular mediators. Mitochondria express functional receptors for estrogen, androgen, glucocorticoids, serotonin, melatonin, cannabinoids, and purinergic signals, allowing them to respond autonomously to extracellular and intracellular cues. These signaling pathways modulate mitochondrial ROS production, bioenergetics, and activation of inflammasomes such as NLRP3, thereby linking mitochondrial function to immune responses and cellular stress adaptation.[175–177] For example, volume-regulated anion channels (VRACs) modulate mitochondrial adaptation during macrophage activation, influencing inflammasome activity and innate immunity.[176]

Mitochondrial transfer between cells, either via tunneling nanotubes or VEs, represents another important mechanism regulating mitochondrial function at the tissue level. Horizontal mitochondrial transfer has been observed in various physiological and pathological contexts, including cancer progression, tissue repair, and immune responses. This intercellular exchange can restore mitochondrial function in damaged cells and modulate cellular metabolism and survival, suggesting therapeutic potential for mitochondrial transplantation strategies.[178,179]

Moreover, mitochondrial metabolites and post-translational modifications play significant roles in fine-tuning mitochondrial activity. For instance, hydrogen sulfide (H2S) modulates mitochondrial dynamics and function through persulfidation of mitochondrial fission regulators, thereby influencing cellular processes such as cytotrophoblast invasion and neuroprotection.[180,181] Similarly, nucleotide pool sanitization enzymes like MTH1 protect mtDNA from oxidative damage, maintaining mitochondrial integrity and platelet function.[182] The interaction of mitochondrial proteins with metabolites such as genistein, which inhibits adenine nucleotide translocase-2, further exemplifies the complex regulation of mitochondrial bioenergetics and cellular differentiation.[183]

Finally, mitochondrial homeostasis is tightly linked to cellular stress responses and transcriptional regulation. Transcription factors such as Kruppel-like factors (KLFs) regulate mitochondrial biogenesis, dynamics, mitophagy, and unfolded protein responses, integrating MQC with broader cellular programs.[184] The heat shock response factor HSF1 also contributes to mitochondrial homeostasis, mediating protective signaling that preserves mitochondrial function under stress.[185]

Collectively, these diverse mechanisms highlight the multifaceted regulation of mitochondrial function beyond classical quality control pathways. They underscore mitochondria as dynamic organelles integrated within cellular networks, capable of responding to metabolic, signaling, and environmental cues to maintain cellular and organismal health. Understanding these regulatory layers offers promising avenues for therapeutic interventions targeting mitochondrial dysfunction in a wide spectrum of diseases.

The Role of MQC in Health

Maintaining cellular energy metabolism

Mitochondria are fundamental organelles responsible for maintaining cellular energy metabolism, primarily through the production of ATP via oxidative phosphorylation. This bioenergetic function is essential for supporting diverse cellular processes and overall homeostasis. The integrity and quality of mitochondria are preserved by MQC mechanisms, which encompass mitochondrial biogenesis, dynamics (fusion and fission), mitophagy, and proteostasis and MDVs. These mechanisms ensure the removal of damaged mitochondria, maintenance of mitochondrial morphology, and adaptation to metabolic demands, thereby sustaining efficient energy production.[186] For instance, in highly energy-dependent cells such as neurons and cardiomyocytes, MQC is critical to meet their substantial ATP requirements and to prevent dysfunction that can lead to neurodegenerative or cardiovascular diseases.[187,188] Disruption of MQC results in accumulation of dysfunctional mitochondria, impaired ATP synthesis, and increased ROS, which exacerbate cellular damage and metabolic imbalance.[189,190]

At the molecular level, mitochondrial dynamics modulate energy metabolism by regulating mitochondrial morphology and distribution to optimize bioenergetic efficiency. Fusion processes enhance mitochondrial connectivity and facilitate the exchange of mitochondrial contents, supporting respiratory capacity, while fission segregates damaged mitochondria for removal via mitophagy.[191,192] The balance of these dynamics is tightly regulated and linked to metabolic states; for example, disturbances in fusion–fission equilibrium impair energy metabolism and contribute to diseases such as diabetes and cancer.[193,194] Moreover, mitochondrial biogenesis, governed by transcriptional coactivators such as PGC-1α and signaling pathways including AMPK, replenishes the mitochondrial pool to meet increased energy demands.[195,196] AMPK activation not only promotes mitochondrial biogenesis but also enhances mitophagy, thereby coordinating energy supply with mitochondrial quality.[195]

Mitochondrial membrane potential (MMP) serves as a critical indicator of mitochondrial health and is integral to ATP synthesis. Beyond its canonical role, MMP functions as a dynamic signaling hub that modulates ROS production, calcium handling, and local MQC, thus influencing cellular energy homeostasis and adaptive responses.[196] Calcium uptake by mitochondria via the mitochondrial calcium uniporter (MCU) further regulates energy metabolism by stimulating dehydrogenases in the tricarboxylic acid cycle, linking intracellular signaling to mitochondrial ATP production.[197] Dysregulation of mitochondrial calcium homeostasis disrupts energy metabolism and is implicated in tumorigenesis and other pathologies.[197]

Inter-organelle communication, especially between mitochondria and lipid droplets, ER, and the nucleus, is crucial for coordinating energy metabolism. Lipid droplet-mitochondria contacts facilitate the transfer of fatty acids for β-oxidation, thereby regulating energy supply and redox balance.[23,198] Similarly, MAMs between ER and mitochondria mediate calcium transfer and lipid metabolism, influencing mitochondrial bioenergetics and cellular energy homeostasis.[199] Furthermore, mitochondrial nuclear signaling pathways modulate the expression of genes involved in mitochondrial function and energy metabolism, ensuring coordinated cellular responses to metabolic stress.[200]

In various physiological and pathological contexts, mitochondrial energy metabolism is dynamically regulated. For example, in adipose tissue, MQC maintains metabolic homeostasis and prevents obesity-related metabolic diseases by regulating energy expenditure and substrate metabolism.[201] In the liver, mitochondrial dysfunction contributes to MAFLD, while interventions targeting mitochondrial quality and energy metabolism, such as herbal compounds from Poria cocos or Polygonum cuspidatum, have shown promise in restoring mitochondrial function and energy homeostasis.[18,202] Similarly, in skeletal muscle, mitochondrial dynamics modulate energy metabolism to adapt to contraction and metabolic demands.[192] In the brain, mitochondrial energy metabolism supports synaptic function and neuronal viability, with MQC mechanisms being essential to prevent neurodegenerative diseases.[187,203]

Pharmacological modulation of mitochondrial energy metabolism and quality control is emerging as a therapeutic strategy. For instance, melatonin enhances mitochondrial biogenesis and mitophagy, improving energy supply under pathological conditions.[204] Small molecules targeting mitochondrial complex I have been shown to restore energy homeostasis and reduce pathological protein accumulation in neurodegenerative disease models.[205] Moreover, modulation of mitochondrial function influences responses to metabolic stress, as observed in diabetes and cardiovascular diseases, where improving mitochondrial bioenergetics alleviates disease progression.[190,206]

In summary, maintaining cellular energy metabolism relies on the intricate regulation of MQC pathways that preserve mitochondrial integrity, dynamics, and function. These processes ensure efficient ATP production, redox balance, and metabolic flexibility, which are vital for cellular health and adaptation to physiological demands. Disruptions in MQC and energy metabolism underlie numerous diseases, highlighting the importance of targeting these pathways for therapeutic interventions.

Antioxidant and anti-apoptotic effects

MQC is critically influenced by the balance between oxidative stress and apoptosis, with antioxidant mechanisms playing a central role in maintaining mitochondrial integrity and cellular survival. A wide array of studies has demonstrated that natural compounds, pharmacological agents, and endogenous proteins exert protective effects against mitochondrial dysfunction by mitigating ROS accumulation and inhibiting mitochondria-mediated apoptosis pathways.

Several natural antioxidants have been shown to alleviate oxidative stress-induced mitochondrial damage and apoptosis. For instance, dioscin, a steroidal saponin, effectively reduces oxidative stress markers such as superoxide anion (O2−) and hydrogen peroxide (H2O2), enhances antioxidant enzyme activities including superoxide dismutase (SOD) and catalase (CAT), and downregulates pro-apoptotic proteins such as Bax, cytochrome c, and caspases in diabetic nephropathy models, thereby preserving mitochondrial respiratory chain function and improving mitophagy and mitochondrial dynamics.[207] Similarly, blueberry anthocyanin extract (BAE) mitigates arsenic-induced cognitive impairment by restoring antioxidant capacity, reducing ROS, and normalizing mitochondrial biogenesis and dynamics through modulation of PGC-1α and SIRT1 pathways.[208] Vitamin K2 also demonstrates neuroprotective effects by suppressing mitochondrial depolarization and ROS accumulation, regulating mitochondrial fusion/fission proteins MFN1/2 and DRP1, and promoting mitophagy via the PINK1/PRKN pathway.[209] These findings underscore the importance of antioxidant compounds in maintaining MQC and preventing apoptosis.

Pharmacological agents with antioxidant properties further exemplify the therapeutic potential of targeting mitochondrial oxidative stress. Dexmedetomidine (DEX) ameliorates hepatic IRI by restoring MMP, enhancing ATP production, reducing oxidative stress, and inhibiting apoptosis, effects mediated through upregulation of sirtuin 3 (SIRT3) and modulation of mitochondrial dynamics proteins such as DRP1 and OPA1.[210] Telmisartan and losartan, angiotensin II receptor blockers with antioxidant activity, improve post-thaw sperm quality by enhancing mitochondrial function, increasing antioxidant enzyme levels (GPX, SOD), reducing lipid peroxidation, and decreasing apoptosis.[211,212] Similarly, Mito-Tempo and berberine protect rabbit sperm during cryopreservation by reducing ROS and apoptosis while improving mitochondrial activity.[213] These agents highlight the role of mitochondrial-targeted antioxidants in preserving mitochondrial integrity and preventing apoptosis in diverse biological contexts.

Endogenous mitochondrial proteins also contribute to antioxidant defense and apoptosis regulation. Mitochondrial sirtuins, particularly SIRT3, maintain mitochondrial function by activating antioxidant enzymes like manganese-dependent superoxide dismutase (MnSOD), inhibiting ROS generation, and suppressing apoptosis through FOXO and p53 pathways.[214] The mitochondrial enzyme cytochrome c oxidase subunit 5A (COX5A) protects against doxorubicin-induced cardiotoxicity by reducing oxidative stress, preserving mitochondrial function, and inhibiting cardiomyocyte apoptosis via the phosphoinositide 3 (PI3K)/protein kinase B (AKT) signaling pathway.[215] SIRT4 modulates mitochondrial dynamics and oxidative stress in retinal Müller glial cells, reducing apoptosis by balancing mitochondrial fusion/fission proteins and decreasing ROS levels.[216] Moreover, hexokinase domain component 1 (HKDC1), a mitochondrial enzyme, protects against calcium oxalate nephrolithiasis by modulating oxidative stress, apoptosis, and mitochondrial function.[217] These mitochondrial proteins are integral to the antioxidant and anti-apoptotic machinery that sustains mitochondrial quality.

Mechanistically, the interplay between oxidative stress and mitochondrial apoptosis involves modulation of MMP, release of pro-apoptotic factors such as cytochrome c, and activation of caspases. Many studies report that antioxidants restore MMP, reduce ROS, and inhibit the mitochondrial apoptotic cascade. For example, melatonin reduces ROS and Bax/Bcl-2 ratio, preventing cytochrome c release and caspase activation in various cell types.[218] Similarly, paeonol, transported into mitochondria via translocater protein (TSPO), alleviates dexamethasone-induced mitochondrial abnormalities and apoptosis by enhancing antioxidant capacity and suppressing pro-apoptotic proteins.[219] The mitochondrial antioxidant SS-31 scavenges ROS, stabilizes mitochondrial dynamics, and inhibits apoptosis and pyroptosis in nucleus pulposus cells.[220] These findings illustrate that antioxidant-mediated preservation of mitochondrial function is crucial to preventing apoptosis.

Furthermore, oxidative stress-induced mitochondrial dysfunction is implicated in various pathological conditions, including neurodegeneration, cardiovascular diseases, reproductive dysfunction, and cancers. Many studies demonstrate that antioxidants and MQC modulators can reverse or attenuate mitochondrial damage and apoptosis in these contexts. For example, astaxanthin protects neurons from oxidative damage and apoptosis by restoring mitochondrial function,[221] while hyperoside protects osteoblasts from phthalate-induced oxidative stress and apoptosis by enhancing mitophagy and activating Nrf2/HO-1 pathways.[222] In cancer models, compounds such as manoalide and nigericin induce apoptosis via oxidative stress and mitochondrial dysfunction, highlighting the therapeutic potential of modulating mitochondrial oxidative balance.[223,224]

In summary, the antioxidant and anti-apoptotic effects are fundamental components of MQC. Antioxidants, whether natural compounds, pharmacological agents, or endogenous mitochondrial proteins, mitigate ROS accumulation, preserve MMP, regulate mitochondrial dynamics, and inhibit the intrinsic apoptotic pathway. These mechanisms collectively maintain mitochondrial integrity and cellular homeostasis, offering promising therapeutic avenues for diseases characterized by mitochondrial dysfunction and oxidative stress-mediated apoptosis.

Imbalance of MQC and Its Association with Diseases

MQC and neurodegenerative diseases

MQC is a critical cellular system that maintains mitochondrial integrity and function, which is particularly vital in neurons due to their high energy demands and complex morphology. Neurodegenerative diseases (NDDs), including AD, PD, HD, and ALS, are characterized by progressive neuronal loss and dysfunction, with mitochondrial dysfunction emerging as a central pathological hallmark. MQC encompasses multiple interconnected processes such as mitochondrial biogenesis, dynamics (fusion and fission), mitophagy, proteostasis, and MDVs, all of which coordinate to surveil, repair, or eliminate damaged mitochondria to preserve cellular homeostasis.[225,226] Impairment in any of these pathways leads to the accumulation of dysfunctional mitochondria, bioenergetic deficits, increased ROS production, and activation of neuroinflammatory cascades, all contributing to neurodegeneration.

In AD, for example, dysregulation of MQC manifests as impaired mitophagy and mitochondrial dynamics, leading to defective clearance of damaged mitochondria and bioenergetic failure. The mitochondrial-associated membranes (MAMs), which mediate communication between mitochondria and the ER, play a pivotal role in regulating MQC and are disrupted in AD, exacerbating mitochondrial dysfunction and neuronal loss.[227,228] Similarly, in PD, mutations in genes such as PINK1 and PRKN, which are central regulators of mitophagy, compromise MQC and lead to the accumulation of damaged mitochondria, triggering dopaminergic neuron degeneration.[226,229] These genetic insights underscore the importance of MQC in maintaining neuronal health and reveal potential molecular targets for intervention.

Moreover, mitochondrial proteostasis maintained by mitochondrial-resident AAA+ proteases is essential for degrading damaged mitochondrial proteins and preventing proteotoxic stress. Failure of these proteases contributes to mitochondrial dysfunction observed in various NDDs.[230] The UPRmt is another adaptive response activated upon mitochondrial stress to restore proteostasis by upregulating chaperones and proteases; its modulation has shown therapeutic potential in models of AD, PD, HD, and ALS.[114] Beyond neurons, MQC in glial cells, including microglia and astrocytes, also influences neurodegeneration by affecting neuroinflammation and neuronal support, highlighting the cell-type-specific complexity of MQC in the brain.[231]

Therapeutic strategies targeting MQC pathways have gained considerable attention. Pharmacological agents that enhance mitophagy, stabilize mitochondrial dynamics, or activate UPRmt show promise in preclinical models by restoring mitochondrial function and slowing disease progression.[232,233] In addition, mitochondrial-targeted drug delivery systems, such as nanoparticles and peptides, are being developed to improve the efficacy and specificity of therapeutics aimed at mitochondrial dysfunction in NDDs.[234] Nutritional supplementation with cofactors essential for mitochondrial function, including Coenzyme Q10, B-vitamins, and antioxidants, has also been explored as adjunctive therapy.[235]

Advanced neuroimaging techniques, such as positron emission tomography (PET) using specific tracers, enable in vivo assessment of mitochondrial oxidative stress and dysfunction, facilitating early diagnosis and monitoring of therapeutic responses in neurodegenerative disorders.[236,237] Furthermore, emerging research highlights the role of mitochondrial retrograde signaling in modulating nuclear gene expression in response to mitochondrial dysfunction, offering additional molecular targets for intervention.[238]

In summary, MQC dysfunction is a convergent mechanism underlying the pathogenesis of major neurodegenerative diseases. The intricate balance of mitochondrial biogenesis, dynamics, proteostasis, mitophagy, and inter-organelle communication is essential for neuronal survival and function. Disruption of these processes leads to mitochondrial damage accumulation, oxidative stress, and neuroinflammation, driving neurodegeneration. Understanding the molecular details of MQC pathways and their dysregulation in disease states provides a foundation for developing targeted therapies that restore mitochondrial integrity, offering hope for effective treatment of neurodegenerative diseases.

MQC and cardiovascular diseases

MQC plays a pivotal role in the maintenance of cardiovascular health by preserving mitochondrial integrity and function in cardiomyocytes and vascular cells, which are highly dependent on mitochondrial ATP production to meet their substantial energy demands. Cardiovascular diseases (CVDs), including IRI, heart failure, hypertrophy, atherosclerosis, hypertension, and diabetic cardiomyopathy, have been closely linked to mitochondrial dysfunction characterized by impaired oxidative phosphorylation, excessive ROS generation, disrupted calcium homeostasis, and activation of cell death pathways.[239–241] MQC ensures the removal of damaged mitochondria and the replenishment of healthy ones, thereby maintaining cellular homeostasis in the cardiovascular system.[242,243]

In the pathogenesis of CVDs, dysregulation of MQC processes leads to the accumulation of dysfunctional mitochondria, which exacerbates oxidative stress and inflammatory responses, contributing to cardiomyocyte death and cardiac remodeling.[239,244] For instance, aberrant mitochondrial fission mediated by DRP1 is an early marker of mitochondrial injury and promotes cardiomyocyte apoptosis, while reduced mitochondrial fusion, regulated by MFN1/2 and OPA1, is linked to mitochondrial fragmentation and impaired bioenergetics in stressed hearts.[243,245] Mitophagy, the selective autophagic clearance of damaged mitochondria, is generally protective by preventing the propagation of mitochondrial dysfunction; however, excessive or insufficient mitophagy can be maladaptive, contributing to cardiac injury.[242,246] Moreover, mitochondrial biogenesis, regulated by transcriptional coactivators such as PGC-1α, is essential for restoring mitochondrial mass and function after injury, and its impairment is associated with heart failure and ischemic cardiomyopathy.[245,247]

Emerging evidence highlights the interplay between MQC and signaling pathways such as the Hippo pathway, which modulates mitochondrial dynamics and mitophagy, influencing cardiomyocyte survival and cardiac regeneration.[248] Additionally, posttranslational modifications of mitochondrial proteins and mitochondrial proteostasis mechanisms, including chaperones and proteases, contribute to MQC and are critical for cardiac function.[188,249] Environmental factors, such as air pollution and mechanical stress, have been shown to impair.

MQC and acute and chronic kidney diseases

MQC plays a pivotal role in maintaining renal cellular homeostasis and function, given the kidney’s high mitochondrial density and energy demands. Acute kidney injury (AKI) and chronic kidney disease (CKD) are characterized by disrupted MQC mechanisms, which contribute to disease pathogenesis and progression.[250] In AKI and CKD, mitochondrial dysfunction arises from maladaptive repair processes in mitochondria-rich renal tubular cells, where impaired mitochondrial bioenergetics, biogenesis, dynamics (fusion and fission), and mitophagy lead to cellular injury and death.[251–254] The dynamic balance of mitochondrial fusion and fission is critical; excessive fission results in mitochondrial fragmentation, promoting oxidative stress and apoptosis, while impaired fusion disrupts mitochondrial networking, further exacerbating injury.[255–257] Mitophagy, the selective autophagic removal of damaged mitochondria, is essential in AKD to prevent the accumulation of dysfunctional mitochondria and subsequent ROS production.[258,259] Defective mitophagy has been implicated in acute tubular injury and maladaptive repair, with key regulators such as PINK1 and PRKN being promising therapeutic targets.[260–262] Pharmacological agents such as resveratrol, L-carnitine, and apelin have demonstrated efficacy in modulating MQC proteins (Pink1, PRKN, BNIP3, DRP1, and PGC-1α), reducing oxidative stress and improving renal ATP levels in AKI models.[259,263] Moreover, serotonin receptor agonists have emerged as novel modulators of mitochondrial biogenesis and homeostasis, offering potential therapeutic avenues in AKI and CKD by restoring mitochondrial function.[264]

In CKD, persistent mitochondrial dysfunction contributes to progressive renal fibrosis and functional decline. Imbalances in mitochondrial dynamics favoring fission over fusion lead to mitochondrial fragmentation, oxidative stress, and inflammation, which are central to CKD pathophysiology.[265,266] Epigenetic regulators such as SIRT6 and GLIS1 modulate mitochondrial biogenesis and dynamics via PGC-1α, attenuating oxidative damage, inflammation, and fibrosis, thereby delaying CKD progression and kidney aging.[267,268] Mitophagy also plays a dual role in CKD; while its activation removes damaged mitochondria and limits ROS-mediated injury, dysregulated mitophagy can exacerbate fibrosis and tubular cell apoptosis.[261,269,270] The interplay between mitophagy and ferroptosis, a form of iron-dependent cell death, is increasingly recognized in renal fibrosis, where mitophagy receptors such as NIP3-like protein X (NIX) inhibit ferroptosis by modulating cystine/glutamate antiporter activity.[269] Additionally, mitochondrial dysfunction in podocytes and tubular epithelial cells disrupts energy metabolism and promotes inflammation, contributing to diabetic kidney disease (DKD) and other CKDs.[271,272] Recent studies highlight the role of MQC in modulating immune responses and inflammation in the kidney, with autophagy and mitophagy attenuating inflammatory cascades and cell death pathways during injury and repair.[273] The ROS accumulation caused by MQC dysfunction is also an important factor contributing to the development of DKD.[274,275]

Experimental models of IRI demonstrate that ischemia duration and reperfusion time critically influence mitochondrial quality, with prolonged ischemia causing bioenergetic failure, disrupted mitochondrial dynamics, and decreased mtDNA copy number, leading to impaired renal recovery.[276] Therapeutic strategies targeting MQC include modulation of mitochondrial proteases such as LONP1, which maintain mitochondrial proteostasis and bioenergetics under stress, and have shown promise in mitigating renal injury.[277,278] Stem cell-derived exosomes carrying microRNAs (e.g., miR-874-3p) can regulate necroptosis and mitochondrial fission via DRP1 dephosphorylation, promoting tubular epithelial cell repair after injury.[279] Furthermore, pharmacological agents such as zileuton attenuate rhabdomyolysis-induced AKI by modulating mitochondrial dynamics and suppressing myeloid-derived suppressor cell-mediated inflammation.[280] Recent studies have shown that mtDNA, as a key molecule linking mitochondrial damage to sterile inflammation, plays a critical role in the pathogenesis of various kidney diseases.[281] The age-dependent accumulation of mt-tRNA mutations in mouse kidneys is closely associated with mitochondrial nephropathy.[282] Targeted regulation of mitochondrial RNA by Mito-tempo may alleviate kidney pathology.[283,284]

In summary, MQC mechanisms encompassing mitochondrial dynamics, mitophagy, biogenesis, and proteostasis are integral to kidney health and disease.[115] Disruptions in these processes underlie the pathogenesis of both acute and chronic kidney diseases, including AKI, CKD, and DKD. Therapeutic interventions aimed at restoring mitochondrial homeostasis and quality control hold significant promise for the complexity of MQC regulation, cell type-specific effects, and potential adverse effects. Future research should focus on elucidating precise molecular pathways, developing targeted therapeutics, and identifying biomarkers to monitor mitochondrial health during kidney injury and repair.[98,285,286]

MQC and metabolic diseases

MQC plays a pivotal role in the pathogenesis and progression of metabolic diseases, which encompass a spectrum of disorders such as metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic syndrome, T2DM, diabetic cardiomyopathy, DKD, and polycystic ovary syndrome (PCOS). These diseases share a common thread of mitochondrial dysfunction characterized by impaired mitochondrial biogenesis, abnormal dynamics (fusion and fission), defective mitophagy, and disrupted proteostasis, leading to compromised energy metabolism, increased oxidative stress, and inflammation. MASLD, formerly known as non-alcoholic fatty liver disease, exemplifies the central role of MQC in metabolic disorders. In MASLD, dysfunctional mitochondria contribute to hepatic steatosis, inflammation, and fibrosis by failing to maintain energy homeostasis and by generating excessive ROS.[287] Experimental models of MAFLD induced by high-fat diet demonstrate increased mitochondrial ROS production, mtDNA damage, reduced mitochondrial biogenesis, impaired fusion, and defective mitophagy, underscoring the failure of MQC as a core event in hepatic mitochondrial dysregulation.[288] These mitochondrial perturbations not only exacerbate lipid accumulation but also activate inflammatory pathways, including the cyclinc GMP-AMP synthase–stimulator of interferon genes (cGAS–STING) axis, which further aggravate liver injury.[289]

In diabetic cardiomyopathy, a major complication of diabetes, MQC dysfunction manifests as excessive mitochondrial fission, reduced fusion, and impaired mitophagy, resulting in the accumulation of fragmented and dysfunctional mitochondria within cardiomyocytes. This mitochondrial derangement promotes oxidative stress, metabolic reprogramming, and cell death, ultimately leading to cardiac dysfunction.[290,291] Therapeutic agents such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists exert cardioprotective effects partly by restoring MQC balance.[291] Similarly, DKD, the leading cause of end-stage renal disease, is characterized by mitochondrial dysfunction due to defective MQC mechanisms, including impaired mitochondrial dynamics, mitophagy, and biogenesis. These defects lead to the accumulation of damaged mitochondria, increased ROS production, and renal tissue injury.[272,292] Natural products and pharmacological agents targeting MQC pathways show promise in ameliorating DKD by restoring mitochondrial homeostasis.[293]

Mitochondrial dysfunction also underlies insulin resistance and metabolic syndrome, conditions marked by obesity, dyslipidemia, and hypertension. Impaired MQC contributes to oxidative stress and chronic low-grade inflammation, which are central to metabolic syndrome pathogenesis.[294,295] For instance, the mitochondrial protease LONP1, a key player in mitochondrial proteostasis, emerges as a potential molecular target for metabolic syndrome therapy.[295] In PCOS, mitochondrial abnormalities in granulosa cells, including decreased MMP, reduced ATP production, and increased ROS, are linked to impaired oocyte quality and reproductive dysfunction. Downregulation of SIRT3, a regulator of mitochondrial function and glucose metabolism, mediates these defects, highlighting the role of MQC in reproductive metabolic disorders.[296,297]

Furthermore, mitochondrial stress responses such as the UPRmt and mitochondrial proteases are integral to MQC and cellular adaptation in metabolic diseases. Their dysregulation exacerbates mitochondrial proteotoxicity, contributing to disease progression.[298,299] Therapeutic strategies enhancing MQC, including nicotinamide adenine dinucleotide (NAD)+ boosters, have demonstrated efficacy in improving mitochondrial function and reducing metabolic dysfunction in diabetes and neurodegenerative disease models.[300] Additionally, interventions such as photobiomodulation and natural compounds (e.g., asperuloside, bavachin) improve mitochondrial function and biogenesis, mitigating metabolic disease phenotypes.[301–303]

In summary, MQC is a fundamental determinant of mitochondrial integrity and function in metabolic diseases. The intricate balance of mitochondrial biogenesis, dynamics, mitophagy, and proteostasis is essential for cellular energy homeostasis and prevention of oxidative damage. Disruption of these processes contributes to the pathogenesis of MASLD, diabetic complications, metabolic syndrome, and PCOS. Targeting MQC pathways offers promising therapeutic avenues to restore mitochondrial function, reduce oxidative stress, and improve metabolic outcomes. Ongoing research continues to elucidate the molecular mechanisms of MQC dysregulation and to develop mitochondria-targeted therapies that may transform the management of metabolic diseases.

MQC and tumors

MQC plays a pivotal role in tumor biology, influencing cancer development, progression, metastasis, and therapeutic responses through the maintenance of mitochondrial homeostasis. Tumor cells exhibit high metabolic demands and mitochondrial activity, which leads to increased production of mitochondrial ROS (mtROS), accumulation of mtDNA mutations, and mitochondrial dysfunction. To survive and proliferate under these conditions, cancer cells exploit MQC mechanisms, including mitochondrial dynamics (fusion and fission), mitophagy, mitochondrial biogenesis, UPRmt, and MDVs, to preserve mitochondrial integrity and function.[233,304,305] For example, the UPRmt is activated in cancer cells to mitigate mitochondrial stress by promoting the refolding or degradation of damaged mitochondrial proteins, thereby supporting tumor growth and resistance to therapy.[233,304] Similarly, mitochondrial dynamics regulated by proteins such as DRP1 are critical for tumor cell survival, proliferation, and metastasis, with DRP1-mediated mitochondrial fission linked to cancer stemness and chemoresistance.[306,307]

In gastrointestinal tumors, disruptions in mitochondrial homeostasis, including altered mitochondrial biogenesis, dynamics, and mitophagy, contribute to tumorigenesis and progression, suggesting that targeting MQC pathways could offer therapeutic benefits.[305] The p53/Mieap-regulated MQC pathway exemplifies the tumor-suppressive role of MQC, where Mieap induces mitochondrial repair or elimination of damaged mitochondria, and its inactivation via promoter methylation or p53 mutation is frequently observed in gastric and esophageal cancers, correlating with impaired mitochondrial apoptosis and tumor progression.[308] Moreover, mitochondrial proteases such as ClPP maintain mitochondrial proteostasis, and their dysregulation is implicated in hematologic and solid tumors, highlighting ATP-dependent unfoldase ClpX (ClpXP) as a potential therapeutic target.[309]

MDVs, selectively remove damaged mitochondrial components and have been shown to influence tumor progression and chemoresistance. In chemoresistant ovarian cancer cells, defective mitochondria–lysosome communication leads to increased MDVs secretion, which can transfer mitochondrial components to recipient cells, modulating mitochondrial function and promoting chemoresistance.[310,311] Additionally, the regulation of mitochondrial plasticity by proteins such as complement C1q binding protein (C1QBP) affects tumor metastasis and immune responses, influencing the competitive balance between tumor and immune cells within the tumor microenvironment.[312,313]

Metabolic reprogramming in tumors is closely linked to MQC. For instance, inhibition of pyruvate dehydrogenase kinase 1 (PDK1) shifts glucose metabolism from glycolysis to oxidative phosphorylation, but concurrently disrupts MQC by altering mitochondrial morphology and reducing mitophagy and biogenesis proteins, leading to increased mitochondrial stress and ROS production.[248] Furthermore, mitochondrial dysfunction induced by targeted therapies or metabolic interventions, such as mitochondrial iron chelation or use of nanosystems inducing mitochondrial damage, has shown promise in suppressing tumor growth and metastasis by exploiting MQC pathways.[314,315]

MQC also intersects with immune regulation in tumors. In hepatocellular carcinoma (HCC), mitochondrial dysfunction in T cells within the tumor microenvironment contributes to T-cell exhaustion, impairing antitumor immunity. Strategies combining immune checkpoint inhibitors with mitochondrial biogenesis modulation aim to restore T-cell function by enhancing MQC.[316] Similarly, mitochondrial dysfunction and MQC dysregulation affect tumor-infiltrating lymphocytes in head and neck squamous cell carcinoma, influencing cytotoxic responses.[317]

Therapeutically, targeting MQC offers multiple avenues. In triple-negative breast cancer (TNBC), abnormal MQC contributes to chemoresistance, immune evasion, metastasis, and cancer stemness, and interventions aimed at key MQC nodes provide potential for precision therapy.[318] Drugs such as berberine and proguanil have been shown to induce mitochondrial dysfunction and apoptosis in tumor cells by modulating MQC pathways.[319,320] Moreover, combining mitochondrial dysfunction-inducing agents with photodynamic therapy or chemotherapy enhances treatment efficacy and overcomes multidrug resistance by disrupting MQC.[321,322]

In summary, MQC is intricately involved in tumor biology, affecting mitochondrial integrity, metabolic adaptation, immune interactions, and therapeutic resistance. The dual role of MQC in maintaining mitochondrial function to support tumor survival and as a potential vulnerability offers promising targets for cancer therapy. Advances in understanding the molecular mechanisms of MQC dysregulation in tumors, along with the development of agents modulating these pathways, could lead to novel and effective anticancer strategies.[233,323,324] Mitochondrial dysfunction and diseases, related regulatory pathways, and intervention strategies are summarized in Table 1.

Table 1.

Mitochondrial dysfunction and diseases.

Diseases Targets and pathways Interventions
NDD PINK1/PRKN,[325] Drp1,[326,327] PGC-1α[328] Mdivi-1,[328,329] Resveratrol analogues,[330] P110,[326] Q10,[331] idebenone,[332] Urolithin A,[333] Mfn2 agonist[334]
CVD mPTP,[335] Drp1,[336] FUNDC1,[337] BNIP3[338] Cyclosporine A,[339] Drp1 inhibitor,[336] SUL-238[340]
AKI, CKD Drp1,[341] PGC-1α,[342] cardiolipin[343] Drp1 inhibitor,[341] SS-31[343]
Cancer Mitophagy,[344] BCL-2,[345] OXPHOS[346] HCQ,[347] venetoclax,[348] IACS-010759,[346] Mdivi-1[349]
Metabolic disease PGC-1α,[350] AMPK,[351] mitophagy[352] Exercise,[350] calorie restriction,[353] metformin,[354] MOTS-c,[355] urolithin A[356]

AMPK: Adenosine monophosphate-activated protein kinase; AKI: Acute kidney injury; BCL-2: B-cell lymphoma 2; BNIP3: BCL2/adenovirus E1B 19 kDa protein-interacting protein 3; CKD: Chronic kidney disease; CVD: Cardiovascular disease; Drp1: Dynamin-related protein 1; FUNDC1: FUN14 domain-containing protein 1; mPTP: Mitochondrial permeability transition pore; NDD: Neurodegenerative diseases; OXPHOS: Oxidative phosphorylation; PGC-1α: Peroxisome proliferator-activated receptor gamma coactivator 1-alpha; PINK1: PTEN-induced kinase 1; PRKN: Parkin.

Targeted MQC Therapeutic Strategies

Enhancing mitophagy

Enhancing mitophagy, the selective autophagic removal of damaged or dysfunctional mitochondria, has emerged as a critical therapeutic strategy in various pathological conditions characterized by mitochondrial dysfunction. In acquired cholesteatoma epithelial cells, mitophagy is notably enhanced, as evidenced by increased expression of autophagy markers LC3-II and mitophagy proteins BNIP3, PRKN, and PINK1, alongside elevated autophagic activity and autophagosome formation, suggesting a potential role of mitophagy in disease pathogenesis.[357] Similarly, in neurodegenerative diseases such as AD, impaired mitophagy contributes to the accumulation of defective mitochondria, exacerbating neuronal damage. Pharmacological induction of mitophagy via enhancers such as urolithin A, NAD+, and resveratrol has shown promise in suppressing mutant amyloid precursor protein (APP)/beta-amyloid (Aβ) and Tau-induced mitochondrial and synaptic dysfunctions, highlighting mitophagy activation as a therapeutic target.[358,359] In osteoarthritis, stabilization of hypoxia-inducible factor-1αpromotes mitophagy, alleviating cartilage degradation by mitigating apoptosis and senescence in chondrocytes under hypoxic conditions, indicating that enhancing mitophagy can protect joint tissues.[360] Moreover, bronchial fibroblasts from severe asthmatic patients exhibit enhanced Pink/PRKN-mediated mitophagy, which contributes to fibroblast persistence and fibrosis, suggesting that modulating mitophagy flux could influence disease progression.[361] Cardioprotective effects of agents such as canagliflozin in diabetic cardiomyopathy are partly mediated by activation of PINK1-PRKN-dependent mitophagy, which improves mitochondrial function and energy metabolism, underscoring the importance of mitophagy enhancement in cardiac diseases.[362] Molecular regulators such as arrestin-3 and Mdm2 have been identified to bind and enhance PRKN activity, facilitating mitophagy and offering novel avenues for therapeutic intervention, especially in PD.[363,364] Nutritional compounds prevalent in Mediterranean and Okinawan diets, including resveratrol, curcumin, and spermidine, also act as mitophagy enhancers, promoting brain health and potentially delaying neurodegeneration by maintaining mitochondrial quality.[365] In neurodegenerative models, inhibition of nuclear receptor NR1D1 enhances autophagy and mitophagy, improving neuronal function and cognitive outcomes, thereby reinforcing the therapeutic potential of mitophagy activation.[366] Experimental evidence from prion-infected cells and animal models demonstrates upregulated PINK1/PRKN-dependent mitophagy as a cellular response to mitochondrial damage, suggesting that enhancing this pathway may mitigate neurodegeneration.[367] Natural compounds such as icaritin induce mitophagy via PINK1/PRKN signaling in HCC cells, and mitophagy inhibition enhances their anticancer efficacy, indicating that fine-tuning mitophagy can modulate therapeutic responses.[368] In the context of sepsis-induced myocardial dysfunction, pharmacological agents such as Baricitinib enhance PINK1-PRKN-mediated mitophagy via inhibition of the Janus kinase 2 (JAK2)-AKT-mTOR pathway, reducing apoptosis and restoring energy metabolism, highlighting mitophagy enhancement as a cardioprotective mechanism.[369] Furthermore, long non-coding RNAs (lncRNAs) such as rhabdomyosarcoma 2 associated transcript (RMST) have been shown to suppress mitophagy through post-translational modifications, suggesting that targeting lncRNAs could modulate mitophagy in gliomas.[370] Coenzyme Q10 (CoQ10) protects against acetaminophen-induced liver injury by promoting mitophagy, emphasizing the role of mitophagy enhancers in drug-induced organ toxicities.[371] Collectively, these studies underscore that enhancing mitophagy through genetic, pharmacological, or nutritional means can restore mitochondrial homeostasis, reduce oxidative stress, and improve cellular function across a spectrum of diseases. The PINK1–PRKN pathway remains a central axis in mitophagy regulation, and its modulation offers promising therapeutic avenues. However, the context-dependent effects of mitophagy, including its role in fibrosis or cancer cell survival, necessitate precise modulation strategies. Advances in understanding mitophagy mechanisms and the development of mitophagy-specific activators or inhibitors will be critical for translating these findings into clinical therapies for mitochondrial-related diseases.

Inhibition of excessive mitochondrial fission

Excessive mitochondrial fission, predominantly mediated by DRP1 and its interaction with adaptor proteins such as Fis1, Mff, MiD49, and MiD51, is a critical pathological hallmark in various diseases, including cardiovascular, neurodegenerative, metabolic, and inflammatory disorders. Under physiological conditions, mitochondrial fission and fusion are tightly balanced to maintain mitochondrial morphology, distribution, and function, which are essential for cellular homeostasis. However, pathological stimuli often trigger aberrant activation of DRP1, leading to excessive mitochondrial fragmentation, mitochondrial dysfunction, increased ROS production, impaired mitophagy, and ultimately cell death or dysfunction. Inhibiting this excessive fission has emerged as a promising therapeutic strategy to restore MQC and improve disease outcomes.

In obesity cardiomyopathy (OCM), lipotoxic stress induced by palmitate leads to excessive mitochondrial fission via DRP1/Fis1 interaction, resulting in mitochondrial dysfunction, increased oxidative stress, and release of extracellular mitochondria (exMito) that propagate inflammation and cardiac remodeling. The peptide inhibitor P110, which selectively disrupts DRP1/Fis1 interaction, effectively attenuates mitochondrial fragmentation, reduces exMito release, and ameliorates inflammation and contractile dysfunction in both in vitro and in vivo OCM models.[372] Similarly, in diabetic cardiomyopathy, abnormal MQC characterized by excessive fission and insufficient fusion contributes to cardiomyocyte injury. Pharmacological agents targeting mitochondrial dynamics, including inhibition of DRP1-mediated fission, have shown cardioprotective effects by restoring mitochondrial morphology and function.[291,373]

In vascular diseases such as atherosclerosis and vascular senescence, excessive mitochondrial fission mediated by DRP1 activation exacerbates mitochondrial dysfunction and oxidative stress. Inhibition of DRP1 with mdivi-1 or blockade of upstream signaling pathways (e.g., AT1R-Raf/MEK/ERK axis) attenuates mitochondrial fragmentation, enhances mitophagy, and reduces vascular inflammation and senescence.[108,374] In neurodegenerative diseases, DRP1 hyperactivation induces pathological mitochondrial fragmentation, contributing to neuronal death. Rho-associated coiled-coil containing kinase 1 (ROCK1) kinase phosphorylates DRP1, promoting excessive fission and impairing mitophagy, while ROCK inhibition restores mitochondrial dynamics and confers neuroprotection in models of PD, AD, and ALS.[63,375,376]

Mitochondrial fission also plays a pivotal role in IRI and neuroinflammation. In myocardial IRI, DRP1-mediated fission leads to mitochondrial fragmentation and cardiomyocyte apoptosis, which can be mitigated by DRP1 inhibitors that promote mitochondrial biogenesis through PGC-1α activation.[328,377,378] In postoperative cognitive dysfunction (POCD), DRP1 inhibition reduces microglial activation, ROS production, and synaptic loss, improving cognitive outcomes.[379] Moreover, in spinal cord injury, MSC-mediated mitochondrial transfer restores mitochondrial fusion and inhibits DRP1-dependent fission, thereby reducing neuronal ferroptosis.[380]

Pharmacological agents such as mdivi-1, P110, and natural compounds have demonstrated efficacy in inhibiting DRP1-dependent mitochondrial fission, preserving mitochondrial function, and attenuating disease progression across multiple organ systems.[380–382] Exercise interventions also modulate DRP1 activity, reducing excessive fission and improving mitochondrial and cellular metabolism in chronic diseases.[383–385] Furthermore, traditional Chinese medicines like Zishen Tongyang Huoxue decoction (TYHX) regulate MQC by inhibiting DRP1 translocation and excessive fission through signaling axes involving VDAC1 and β-tubulin, offering additional therapeutic avenues.[374]

Mechanistically, post-translational modifications of DRP1, including phosphorylation at Ser616 enhance its recruitment to mitochondria and fission activity, while inhibition of these modifications or blocking DRP1 assembly reduces pathological fission.[386–388] Targeting upstream regulators such as nuclear receptor subfamily 4 group A member 1 (NR4A1), methyltransferase-like 3 (METTL3), and ROCK1, which modulate DRP1 activity and mitochondrial dynamics, also represents a promising strategy to curb excessive mitochondrial fission and its deleterious consequences.[389–391]

In summary, inhibition of excessive mitochondrial fission by targeting DRP1 and its regulatory network is a critical component of MQC restoration. This approach holds significant therapeutic potential for a broad spectrum of diseases characterized by mitochondrial dysfunction, including cardiovascular diseases, neurodegenerative disorders, metabolic syndromes, and inflammatory conditions. Ongoing research into specific inhibitors, signaling pathways, and combinatorial therapies will further refine strategies to suppress pathological mitochondrial fission while preserving physiological mitochondrial dynamics essential for cellular health.

MQC as a novel therapeutic target: Future research directions and clinical applications

MQC has emerged as a pivotal therapeutic target across a spectrum of diseases, reflecting its fundamental role in maintaining cellular homeostasis and organ function. Dysfunctional MQC mechanisms—including impaired mitophagy, disrupted mitochondrial dynamics (fusion/fission), defective mitochondrial biogenesis, and compromised protein quality control—are implicated in the pathogenesis of neurodegenerative disorders, cardiovascular diseases, metabolic syndromes, cancers, and inflammatory conditions. The translational potential of targeting MQC lies in its ability to restore mitochondrial integrity, reduce oxidative stress, and modulate cell death pathways, thereby ameliorating disease progression and improving clinical outcomes.

In neurodegenerative diseases such as PD, AD, and HD, defective MQC leads to the accumulation of damaged mitochondria, increased ROS, and impaired bioenergetics, which exacerbate neuronal loss and cognitive decline. Pharmacological strategies that enhance mitophagy, modulate mitochondrial dynamics, or promote mitochondrial biogenesis have shown promise in preclinical models, suggesting avenues for disease-modifying therapies.[225,232,392] For example, interventions such as intermittent fasting combined with exercise can augment NADPH levels and mitophagy, thereby protecting neurons from oxidative and proteotoxic stress in PD.[393] Moreover, mitochondrial proteases and chaperones are being explored as druggable targets in cancer therapy, with modulators of ClPP and LonP1 proteases undergoing clinical evaluation.[394]

Cardiovascular diseases, including diabetic cardiomyopathy and anthracycline-induced cardiotoxicity, also exhibit MQC impairment characterized by mitochondrial fragmentation, defective mitophagy, and reduced biogenesis. Therapeutic agents targeting these pathways, such as Sirtuin activators and natural compounds, have demonstrated cardioprotective effects by preserving mitochondrial function and reducing oxidative damage.[291,395,396] Similarly, in IRI and heart failure, restoring MQC balance through modulation of mitochondrial dynamics and autophagy represents a promising strategy to limit myocardial damage.[243,397]

In metabolic diseases and organ-specific pathologies, MQC-targeted therapies are gaining traction. For instance, in osteoarthritis and osteoporosis, mitochondrial dysfunction in chondrocytes and bone cells contributes to disease progression; agents that enhance mitochondrial biogenesis and mitophagy, such as Sirtuin activators, show potential to restore tissue homeostasis and function.[398,399] In pulmonary diseases such as chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis, targeting molecules involved in mitochondrial dynamics (e.g., PINK1, DRP1) may mitigate oxidative stress and cellular senescence, although the complexity of mitochondrial autophagy roles necessitates further investigation.[400,401] Moreover, MQC modulation holds promise in kidney diseases, including acute and diabetic kidney injury, where maintaining mitochondrial homeostasis can prevent cell death and fibrosis.[292,402]

Recent advances highlight innovative therapeutic modalities such as mitochondrial transplantation, mitochondrial-targeted antioxidants, nanozyme-based delivery systems, and MitoEVs that facilitate intercellular mitochondrial transfer and quality control, opening new frontiers for clinical application.[147,403] Epigenetic regulation of MQC components, including DNA methylation and non-coding RNAs, also represents an emerging area for therapeutic intervention, particularly in liver fibrosis and cancer.[404,405]

Despite these advances, several challenges impede clinical translation. These include the heterogeneity of mitochondrial dysfunction across diseases and patients, off-target effects of MQC modulators, limited specificity of delivery systems, and the need for reliable biomarkers to monitor mitochondrial health and therapeutic efficacy. Future research should prioritize the development of personalized MQC-based therapies guided by biomarker profiling, refinement of targeted delivery technologies, and comprehensive evaluation of long-term safety and effectiveness in clinical trials.

In conclusion, MQC represents a versatile and compelling target for therapeutic development across diverse diseases. Continued elucidation of MQC molecular mechanisms, coupled with innovative drug design and delivery approaches, holds the promise of transforming disease management and improving patient outcomes in the coming years.[151,186,406]

Emerging Therapies Targeting Mitochondrial Dysfunction

Small molecule drugs

Small molecule drugs have emerged as promising agents for modulating MQC mechanisms, offering therapeutic potential across a broad spectrum of diseases characterized by mitochondrial dysfunction. These compounds can target key mitochondrial processes such as dynamics (fusion and fission), mitophagy, biogenesis, and proteostasis, thereby restoring mitochondrial homeostasis and cellular health. For instance, natural small molecules such as notoginsenoside R1 (NGR1) have demonstrated efficacy in sepsis models by targeting DRP1-mediated mitochondrial fission, preventing mitochondrial fragmentation, and improving organ function and survival outcomes.[407] Similarly, caffeine at low doses alleviates high-altitude pulmonary edema by promoting PINK1/PRKN-dependent mitophagy and mitochondrial fission, highlighting its role in maintaining mitochondrial quality under hypoxic stress.[408] In the context of infectious diseases, small molecules such as MLN8054, an Aurora kinase A inhibitor, have been identified through organoid-based drug screening to reverse Helicobacter pylori VacA-induced mitochondrial damage in gastric pit cells, underscoring the utility of small molecules in mitigating pathogen-induced mitochondrial dysfunction.[409]

Beyond natural compounds, synthetic small molecules have also been developed to directly modulate MQC pathways. Niclosamide, a PINK1 activator, mitigates paclitaxel-induced peripheral neuropathy by restoring mitochondrial homeostasis and suppressing mitochondrial ROS and aberrant mitophagy in neuronal models.[410] Targeting mitochondrial proteostasis, small molecules such as ONC201 hyperactivate ClpP protease, disrupting mitochondrial protein quality control and offering potential therapeutic avenues in cancer.[411] In neurodegenerative diseases, UMI-77, a BH3-mimetic, induces mitophagy by enhancing MCL1’s interaction with LC3A, thereby improving cognitive function in AD models.[412] Similarly, small molecule modulators of mitophagy are being systematically characterized to ensure methodological rigor and therapeutic efficacy, as highlighted in comprehensive reviews that propose frameworks for evaluating such compounds.[413]

Small molecules also exert protective effects in metabolic and cardiovascular diseases by modulating mitochondrial dynamics and bioenergetics. KU-596, improves mitochondrial bioenergetics and reduces mitophagy in diabetic sensory neurons via heat shock protein 70 (Hsp70)-dependent mechanisms.[414] Pharmacological agents such as metformin and resveratrol enhance mitochondrial biogenesis through activation of PGC-1α, AMPK, and SIRT1 pathways, offering metabolic benefits.[415] In cardiovascular contexts, compounds targeting mitochondrial dynamics and metabolism in macrophages modulate inflammatory responses and cell death, thereby influencing disease progression.[416] Traditional Chinese medicine formulations such as Linggui Zhugan decoction have been shown to ameliorate doxorubicin-induced cardiotoxicity by preserving mitochondrial structure and function through the AMPK-FOXO3a-B cell translocation gene (BTG2) axis.[417]

In oncology, small-molecule drugs targeting mitochondrial dynamics and function present innovative therapeutic strategies. For example, methiothepin, a serotonin receptor antagonist, suppresses tumor growth in placental choriocarcinoma by attenuating mitochondrial function and inducing metabolic shifts.[418] Benzothiophene derivatives identified via high-content screening enhance basal mitophagy, improving mitochondrial function and insulin secretion in beta cells.[419] Small molecules that activate mitochondrial fusion or inhibit fission, such as novel isoxazole derivatives and indomethacin-based compounds, restore mitochondrial morphology and induce apoptosis in HD and various cancer cell models.[420,421] Additionally, small molecule inhibitors of deubiquitinases such as ubiquitin-specific protease 30 (USP30) modulate mitophagy pathways and are being explored for neurodegenerative diseases.[422]

Emerging approaches also involve small molecules that modulate mitochondrial electron flow and redox status, providing novel means to assess and restore mitochondrial quality.[423] Fluorescent small molecule probes conjugated with mitochondria-targeting moieties enable imaging and photodynamic therapy, exemplified by NIR-II fluorophores and aggregation-induced emission (AIE) probes that combine diagnostic and therapeutic functions.[424,425] Furthermore, small molecules that regulate mitochondrial calcium channels and lysosomal function, such as transient receptor potential mucolipin 1 (TRPML1) agonists, mitigate mitochondrial damage and oxidative stress, highlighting the interconnectedness of mitochondrial and lysosomal quality control.[426]

Collectively, these studies illustrate the diverse chemical space of small-molecule drugs capable of targeting MQC mechanisms. Their ability to modulate mitochondrial dynamics, mitophagy, biogenesis, proteostasis, and bioenergetics positions them as versatile tools for treating diseases ranging from neurodegeneration and metabolic disorders to cancer and infectious diseases. Ongoing efforts to optimize their specificity, efficacy, and delivery, including the use of organoid models and structure-based drug design, are critical for translating these promising agents into clinical therapies.[151]

Gene therapy

Gene therapy has emerged as a promising and innovative approach for treating mitochondrial diseases and dysfunctions by directly targeting the underlying genetic defects within mtDNA or nuclear-encoded mitochondrial genes. Unlike traditional symptomatic management, gene therapy aims to correct or compensate for the defective genes responsible for mitochondrial dysfunction, thereby restoring mitochondrial integrity and function. Advances in molecular biology and gene editing technologies, such as clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9), transcription activator-like effector nucleases (TALENs), zinc finger nucleases, and base editors, have facilitated the development of strategies to manipulate mitochondrial genomes or nuclear genes encoding mitochondrial proteins with increasing precision and efficacy.[427–431] These approaches include mitochondrial gene replacement, allotopic expression (nuclear expression of mitochondrial genes with mitochondrial targeting sequences), mitochondrial genome editing, and mitochondrial RNA interference.

A critical challenge in mitochondrial gene therapy is the unique biology of mitochondria, including their double-membrane structure, polyploidy of mtDNA, heteroplasmy (coexistence of mutant and wild-type mtDNA), and limited DNA repair mechanisms. These factors complicate the delivery and editing of mitochondrial genes compared to nuclear genes.[432,433] To overcome these hurdles, novel delivery systems such as adeno-associated virus (AAV) vectors, lipid nanoparticles, and mitochondria-targeted nanocarriers have been developed to facilitate efficient and targeted transduction of mitochondrial or nuclear genes influencing mitochondrial function.[52,434–436]

Several preclinical and clinical studies have demonstrated the therapeutic potential of gene therapy in various mitochondrial diseases. For instance, AAV9-mediated gene therapy delivering functional copies of mitochondrial genes such as deoxyguanosine kinase (DGUOK) and NADH:ubiquinone oxidoreductase subunit S6 (NDUFS6) has shown efficacy in preventing or ameliorating mitochondrial hepatocerebral DNA depletion syndrome and mitochondrial cardiomyopathy, respectively, in mouse models.[434,437] In neurodegenerative diseases such as PD and AD, gene therapy strategies targeting mitochondrial complex I dysfunction via allotopic expression of yeast NDI1 or other mitochondrial genes have improved mitochondrial function and reduced neuropathological features in cell and animal models.[438,439] Similarly, gene editing of the SMN1 gene in spinal muscular atrophy models has shown promise in restoring mitochondrial function in skeletal muscle.[440]

In addition to monogenic mitochondrial diseases, gene therapy is being explored for complex disorders where mitochondrial dysfunction plays a pivotal role, such as sarcopenia, cardiac hypertrophy, and metabolic syndromes. For example, gene therapy targeting MQC protein such as oligomycin sensitivity conferring protein (OSCP) has demonstrated protective effects against cardiac hypertrophy by improving mitochondrial respiration and reducing oxidative stress.[433] Moreover, gene therapies modulating mitochondrial dynamics and biogenesis through pathways involving RAB5A, member RAS oncogene family (Rab5a)/mTOR have shown potential in ameliorating sarcopenia associated with T2DM.[441]

The development of mitochondrial gene editing tools has advanced significantly, with the emergence of base editing technologies capable of precise mtDNA modifications without inducing double-strand breaks, thereby minimizing off-target effects and genomic instability.[431,442] However, efficient delivery of gene editing components into mitochondria remains a major obstacle, necessitating further research into mitochondrial import mechanisms and vector optimization.[429,432]

Clinical translation of mitochondrial gene therapy faces challenges, including heterogeneity of mitochondrial diseases, tissue-specific delivery, immune responses to vectors, and long-term safety concerns. Nonetheless, ongoing clinical trials, particularly for Leber hereditary optic neuropathy (LHON), exemplify the progress toward effective gene-based treatments.[427,443] Additionally, gene therapy approaches are being combined with other modalities such as mitochondrial transplantation, antioxidant therapy, and metabolic interventions to enhance therapeutic outcomes.[52,444]

In summary, gene therapy targeting mitochondrial dysfunction represents a rapidly evolving field with significant therapeutic potential. Advances in gene delivery systems, genome editing technologies, and understanding of mitochondrial biology are paving the way for personalized and effective treatments for mitochondrial diseases and related disorders. Continued research is essential to overcome current limitations and translate these promising strategies into clinical practice to improve patient outcomes.[427,428,432,443]

Nutritional interventions

Nutritional interventions have emerged as a pivotal strategy for modulating MQC and improving health outcomes in various diseases, particularly those associated with aging, metabolic dysfunction, and muscle degeneration. A growing body of evidence underscores the role of specific nutrients, dietary patterns, and bioactive compounds in enhancing mitochondrial biogenesis, dynamics, mitophagy, and oxidative phosphorylation, thereby preserving mitochondrial function and cellular homeostasis. Medium-chain fatty acids (MCFAs), especially caprylic acid (C8), have been demonstrated to promote mitophagy via the PINK1–PRKN pathway, enhance oxidative phosphorylation, reduce mitochondrial oxidative stress, and facilitate skeletal muscle differentiation and maturation, suggesting their therapeutic potential in sarcopenia management.[445] Similarly, omega-3 polyunsaturated fatty acids (PUFAs) have been linked to improved muscle membrane composition and function, attenuation of pro-inflammatory oxidative stress, and activation of mitochondrial signaling pathways, which collectively support physical performance across the lifespan.[446] Dietary antioxidants such as chlorogenic acid and resveratrol have shown efficacy in ameliorating high-fat diet-induced mitochondrial dysfunction and oxidative stress in skeletal muscle and intestinal tissues, respectively, by promoting mitochondrial biogenesis and enhancing antioxidant defenses.[447,448] Moreover, multi-ingredient nutritional supplements containing compounds such as α-lipoic acid, CoQ10, and green tea extract have been associated with improved mitochondrial function, weight loss, and metabolic health in overweight and obese individuals, highlighting the translational relevance of mitochondrial-targeted nutrition.[449]

Dietary patterns such as the Mediterranean diet and ketogenic diet exert beneficial effects on mitochondrial health by modulating oxidative phosphorylation, mitochondrial dynamics, and mitophagy, which are critical in the prevention and management of metabolic diseases including non-alcoholic fatty liver disease (NAFLD) and MASLD.[450,451] Ketogenic diets have demonstrated cardioprotective effects in diabetic models by balancing mitochondrial dynamics and inhibiting apoptosis through the PI3K/AKT pathway, further emphasizing the role of nutritional ketosis in mitochondrial preservation.[452] Time-restricted eating, a form of intermittent fasting, has been shown to improve mitochondrial function and quality of life in patients with postural orthostatic tachycardia syndrome, suggesting that meal timing and caloric restriction can positively influence mitochondrial bioenergetics.[453] Caloric restriction itself remains a cornerstone intervention that enhances mitochondrial biogenesis and function, partly through upregulation of PGC-1α, a master regulator of mitochondrial metabolism, thereby contributing to longevity and reduced incidence of age-related diseases.[454,455]

Micronutrients and bioactive compounds such as vitamin D, minerals, polyphenols, and urolithin A have demonstrated modulatory effects on mitochondrial function and oxidative stress, which translate into improved muscle health, reduced inflammation, and enhanced metabolic resilience.[456–459] For instance, urolithin A, a gut microbiome-derived metabolite, activates mitophagy and MQC pathways, resulting in improved muscle function during aging and reduced cardiovascular risk markers in humans.[459,460] The interplay between diet, microbiome, and mitochondria is increasingly recognized as a critical axis influencing systemic health, with dietary fibers and fermented foods modulating gut microbial composition and mitochondrial function synergistically.[461,462]

In pathological contexts such as obesity, high-fat diets induce mitochondrial dysfunction, oxidative stress, and inflammation, contributing to skeletal muscle and renal injury. Nutritional interventions targeting mitochondrial health, including antioxidant supplementation and modulation of lipid metabolism, have shown promise in mitigating these adverse effects.[458,463,464] Furthermore, specific dietary components such as manganese at tolerable upper intake levels, can activate mitophagy and restore mitochondrial function in neurodegenerative disease models, exemplifying the therapeutic potential of micronutrient optimization.[465]

Emerging nutritional strategies also encompass the use of nanotechnology to enhance the bioavailability and efficacy of mitochondrial-targeted compounds, as demonstrated in animal studies with resveratrol-loaded nanoparticles and other nutraceutical nanocompounds, which improve antioxidant capacity, mitochondrial function, and exercise performance.[466] Additionally, dietary interventions have been explored in clinical settings for neurological disorders such as migraine and neurodegeneration, where co-supplementation with alpha-linolenic acid and L-carnitine or antioxidant-rich diets have shown potential benefits mediated through mitochondrial protection and anti-inflammatory effects.[462,467]

Collectively, these findings highlight those nutritional interventions, ranging from specific fatty acids and vitamins to comprehensive dietary patterns and supplementation strategies, play a crucial role in maintaining MQC and function. Such interventions offer promising avenues for the prevention and management of age-related sarcopenia, metabolic diseases, neurodegenerative disorders, and cardiovascular conditions. Future research should aim to elucidate optimal nutrient combinations, dosing regimens, and personalized approaches integrating genetic and microbiome profiles to maximize mitochondrial health and overall clinical outcomes.

Mitochondrial transplantation

Mitochondrial transplantation involves the delivery of healthy, functional mitochondria into damaged or dysfunctional cells, aiming to restore cellular energy metabolism and improve cell viability. Mitochondrial transplantation technology (MTT) involves the isolation of healthy, functional mitochondria from donor cells or tissues and their subsequent delivery into recipient cells or tissues harboring dysfunctional mitochondria. This process aims to replenish or replace defective mitochondria, thereby restoring bioenergetic capacity and ameliorating cellular and tissue dysfunction.[468,469] The concept of mitochondrial transplantation is inspired by the natural intercellular mitochondrial transfer phenomena observed in physiological and pathological contexts. Cells can exchange mitochondria through tunneling nanotubes, VEs, or direct uptake mechanisms, facilitating the rescue of damaged cells by restoring mitochondrial function.[470,471] Harnessing this intrinsic cellular capability, exogenous mitochondrial transplantation seeks to augment or substitute defective mitochondria in target tissues. Preclinical studies have demonstrated the feasibility and therapeutic benefits of MTT in diverse disease models, including IRI of the heart, neurodegenerative diseases, acute lung injury, and metabolic disorders.[472–475] Encouragingly, early-phase clinical trials, particularly in cardiac IRI, have shown safety and potential efficacy, marking a critical milestone towards clinical translation.[476,477] Furthermore, techniques such as mitochondrial base editing using double-stranded DNA deaminase toxin A-derived cytosine base editor (DdCBE) or CRISPR-based approaches enable correction of pathogenic mtDNA mutations or enhancement of mitochondrial bioenergetics in donor mitochondria, advanced MTT in autologous mitochondrial modification and transplantation.[478,479]

Despite these promising advances, several challenges remain before mitochondrial transplantation can be widely adopted in clinical practice. Key issues include optimizing mitochondrial isolation techniques to ensure viability and functionality, determining the most effective delivery routes and dosages, and understanding the mechanisms governing mitochondrial internalization and integration into host cells.[480,481] Moreover, the immunogenicity of transplanted mitochondria, especially in allogeneic settings, and the stability of mitochondria in extracellular environments rich in calcium ions pose significant hurdles.[469,482] Advances in engineered mitochondria and synthetic biology approaches offer potential solutions to enhance mitochondrial stability, targeting, and therapeutic efficacy.[483] Additionally, the development of biomaterials and delivery systems to facilitate mitochondrial uptake and retention in target tissues is an active area of research.[484] The optimization and innovation in mitochondrial transplantation encompass the integration of biomaterials, nanotechnology, gene editing, and multimodal therapies. These strategies enhance mitochondrial viability, targeting, and therapeutic potential, paving the way for effective clinical applications across a spectrum of mitochondrial-related diseases.

Conclusions and Future Directions

MQC stands as a cornerstone in maintaining cellular health and preventing a broad spectrum of diseases. From an expert perspective, the evolution of research in this field has illuminated the intricate mechanisms by which cells monitor and preserve mitochondrial integrity, including processes such as mitophagy, mitochondrial biogenesis, and dynamics such as fission and fusion. These mechanisms collectively ensure the removal of damaged mitochondria and the replenishment of functional ones, thereby sustaining cellular energy homeostasis and reducing oxidative stress.

Balancing the diverse research perspectives reveals a complex but coherent picture: while some studies emphasize the pivotal role of mitophagy in neurodegenerative diseases, others highlight mitochondrial biogenesis as a therapeutic target in metabolic disorders. This diversity underscores the necessity of an integrated approach that considers the multifaceted nature of MQC pathways and their tissue-specific roles. For instance, in neurodegenerative diseases such as PD and AD, impaired mitophagy leads to the accumulation of dysfunctional mitochondria, contributing to neuronal death. Conversely, in metabolic syndromes and cardiovascular diseases, dysregulated mitochondrial dynamics and biogenesis disrupt energy metabolism and promote pathological remodeling.

The impact of these findings extends beyond basic science, offering promising avenues for therapeutic intervention. Targeting MQC mechanisms holds potential for the development of novel treatments aimed at restoring mitochondrial function. Pharmacological agents that enhance mitophagy or stimulate mitochondrial biogenesis could mitigate disease progression by reinstating cellular homeostasis. Moreover, advances in gene editing and molecular biology provide tools to modulate specific components of MQC pathways, paving the way for personalized medicine approaches.

However, the translation of these insights into clinical practice demands careful consideration of the balance between mitochondrial turnover and cellular demands. Excessive activation of mitophagy, for example, may lead to unintended depletion of mitochondria, whereas insufficient clearance allows accumulation of damaged organelles. Therefore, future research must strive to delineate the optimal modulation of MQC tailored to distinct pathological contexts.

Looking ahead, the future of MQC research and its therapeutic translation hinges on several critical advancements. First, there is a pressing need to move beyond conventional small molecules and develop next-generation therapeutics, such as mitochondria- or MQC-component-specific PROTACs and degraders, to achieve precise and potent modulation of dysfunctional pathways with minimized off-target effects.[485] Second, the development of advanced spatiotemporal biosensors for real-time, dynamic monitoring of MQC processes in vivo is essential to capture the nuanced and transient changes in mitochondrial health during disease progression and therapeutic intervention.[485,486] Third, generating comprehensive, human tissue-specific multi-omics atlases (encompassing transcriptomic, proteomic, and lipidomic data) of MQC networks across the spectrum of health, aging, and various diseases will be invaluable for deciphering context-dependent regulatory logic and identifying novel, disease-specific nodal points for intervention.[318,487] Fourth, the precise and context-dependent role of MDVs, a rapidly evolving MQC pathway, in different pathological settings—such as neurodegeneration or metabolic disease—requires systematic elucidation to harness its full diagnostic and therapeutic potential.[233] Finally, integrating artificial intelligence and machine learning with the burgeoning multi-omics and clinical data holds transformative promise for accelerating the discovery of robust MQC-related biomarkers for early diagnosis and patient stratification, as well as for streamlining the identification and optimization of novel drug candidates.[485] Addressing these interconnected frontiers will be pivotal in translating our mechanistic understanding of MQC into effective, personalized therapies for a wide array of human diseases.

In summary, the ongoing exploration of MQC mechanisms enriches our understanding of cellular physiology and disease etiology. By harmonizing diverse research findings and addressing the challenges of therapeutic targeting, the field is poised to contribute significantly to improving human health. Continued interdisciplinary efforts will be essential to harness the full potential of MQC-based strategies, ultimately transforming the management of metabolic, neurodegenerative, and cardiovascular diseases.

Funding

This work was supported by grants from the National Natural Science Foundation of China (NOs. 82370705, 82370730, and 82172502), Guangdong Provincial Key Laboratory of Autophagy and Major Chronic Non-Communicable Diseases (No. 2022B1212030003), the National Clinical Key Specialty Construction Project (Institute of Nephrology, Affiliated Hospital of Guangdong Medical University), and Special Project for Clinical and Basic Sci and Tech Innovation of Guangdong Medical University (No. GDMULCJC2024001).

Conflicts of interest

None.

Footnotes

How to cite this article: Liu ZZ, Hu WB, Sun L, Liu HF. Mitochondrial quality control in health and disease: Updates 2026. Chin Med J 2026;139:2851–2884. doi: 10.1097/CM9.0000000000004169

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