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Cytidine monophosphate

Cytidine monophosphate (CMP), also known as 5'-cytidylic acid, is a consisting of the attached to a via a β-N1-glycosidic bond, with a group esterified at the 5' position of the ribose. Its is C₉H₁₄N₃O₈P, and it has a molecular weight of 323.2 g/mol. CMP serves as a fundamental building block in the synthesis of , where it is incorporated as one of the four canonical alongside (AMP), (GMP), and (UMP). In nucleotide metabolism, CMP is synthesized primarily through the pathway, involving the conversion of uridine triphosphate (UTP) to cytidine triphosphate (CTP) by CTP synthase, followed by stepwise to CMP. It can also be generated via salvage pathways, such as the of to CMP by uridine- kinase. CMP itself is more commonly derived from higher phosphates. Biochemically, CMP functions as a precursor for the production of higher-energy nucleotides like CDP and CTP, which are essential for synthesis, biosynthesis, and energy transfer processes. The UMP/CMP catalyzes the of CMP to CDP using ATP as the phosphate donor, with reported kinetic parameters including a Km for CMP of 0.028 and a kcat of 91.9 s⁻¹ in bacterial systems. Deoxy forms, such as dCMP, arise from CDP via and support . Beyond its core metabolic roles, CMP has been studied for potential therapeutic applications, including its administration alongside (UMP) to improve exercise performance in animal models by facilitating into muscles and preserving hepatic stores. It is naturally present in biological fluids such as and , and has been detected in studies of conditions like and neurodegenerative diseases including Alzheimer's.

Definition and Properties

Nomenclature and Formula

Cytidine monophosphate (CMP) is a composed of the base linked to a through a β-N1-glycosidic bond, with a group attached via esterification at the 5' position of the ribose. This structure positions CMP as a key building block for , where it serves as one of the four canonical monomers alongside (AMP), (GMP), and (UMP). The compound is commonly referred to as cytidylic acid, cytidine 5'-monophosphate (CMP), or 5'-CMP, reflecting its role as the 5'-phosphorylated derivative of cytidine. Its systematic IUPAC name is (2R,3S,4R,5R)-5-(4-amino-2-oxopyrimidin-1-yl)-3,4-dihydroxyoxolan-2-ylmethyl dihydrogen phosphate, which precisely describes the stereochemistry and atomic connectivity of the molecule. The molecular formula of cytidine monophosphate is C₉H₁₄N₃O₈P, with a molar mass of 323.198 g/mol. Historically, it has been termed cytidylic acid in early biochemical literature to denote the phosphoric acid ester of cytidine, a naming convention that parallels other nucleotides like adenylic acid; this distinguishes it from deoxycytidine monophosphate (dCMP), which features a deoxyribose sugar instead of ribose and functions primarily in DNA.

Physical and Chemical Properties

Cytidine monophosphate (CMP) appears as a crystalline powder. It exhibits high in , approximately 100 mg/mL at 20°C, forming clear solutions, while it is sparingly soluble in and other solvents. The values of CMP are 0.8 for the first of the group, 4.5 for protonation at the N3 position of the base, and 6.3 for the second of the group. These values influence its ionization state at physiological , where the is predominantly dianionic. CMP displays absorption with a maximum at 271 and a extinction coefficient (ε) of 8,740 M⁻¹ cm⁻¹ at neutral . The compound is stable in neutral aqueous solutions but undergoes under acidic or alkaline conditions, leading to cleavage of the or glycosidic bonds. It is also sensitive to enzymatic degradation by phosphatases that target the group. In terms of chemical reactivity, the phosphate group of CMP serves as a in phosphorylation reactions catalyzed by kinases, facilitating the transfer to form diphosphates. Additionally, the cytosine base is susceptible to hydrolytic , converting it to uracil under certain conditions.

Structure

Molecular Components

Cytidine monophosphate (CMP) consists of three primary molecular components: the nucleobase , the pentose sugar , and a single phosphate group, which are covalently linked to form the structure. The is , a ring derivative described as 4-aminopyrimidin-2(1H)-one, featuring an exocyclic amino group at the C4 position and a keto group at the C2 position. This connects to the sugar moiety through an N-glycosidic bond, specifically between the nitrogen at position N1 of and the anomeric carbon C1' of . The sugar component is β-D-ribofuranose, the five-membered ring form of D-, which includes hydroxyl groups at the 2', 3', and 5' positions. The 2' and 3' hydroxyls are particularly important, as they participate in phosphodiester linkages that form the backbone. In contrast to deoxycytidine monophosphate (dCMP), which uses 2-deoxyribose lacking the 2'-OH group, CMP retains this hydroxyl substituent, distinguishing it as a . The is a monophosphate group (–OPO₃H₂), attached via a bond to the 5'-CH₂OH of the , forming a 5'-ester linkage. At physiological (approximately 7.4), the phosphate exists predominantly in its dianionic ionization state (–OPO₃²⁻), due to the values of the phosphate group (pKa₁ ≈ 0.9, pKa₂ ≈ 6.3). These components assemble into CMP through the specified N-glycosidic and 5'-phosphoester bonds, yielding the canonical with the formula C₉H₁₄N₃O₈P.

Stereochemistry and Conformation

Cytidine monophosphate (CMP) exhibits primarily through its sugar moiety, which contains four chiral centers at the C1', C2', C3', and C4' positions, configured as β-D-ribofuranose with absolute (2R,3S,4R,5R). This β-D configuration positions the base above the plane of the ring on the β-face at the anomeric C1', while the hydroxyl groups at C2' and C3' are cis-oriented, essential for the molecule's incorporation into structures. The group attached to the C5' methylene is achiral, consisting of a dihydrogen ester that does not introduce additional stereocenters. The base in CMP predominantly exists in the amino-keto ic form (4-amino-2(1H)-pyrimidinone), which is stabilized by intramolecular hydrogen bonding and is the form observed in most biological contexts. The rare imino-enol (4-imino-2-hydroxypyrimidine) occurs at low populations, estimated at less than 0.1% in neutral , but can influence base pairing fidelity when transiently populated. In protonated states, such as at low pH, keto-iminol tautomerism becomes more accessible, with the C⁺-iminol form detectable via spectroscopic methods and implicated in altered base recognition. Conformational preferences of CMP are dominated by the glycosidic torsion angle (χ, defined as O4'-C1'-N1-C6), which favors the anti range (χ ≈ -120° to -180°) in aqueous solution and crystalline states, positioning the base away from the sugar for optimal stacking in nucleic acids. The syn conformation (χ ≈ 0° to 60°) is energetically disfavored but can appear under specific conditions like protonation. The ribose sugar adopts a C3'-endo pucker (North conformation) as the predominant form in solution, characterized by pseudorotation phase angle P ≈ 0°-36°, which shortens the C1'-C4' distance and aligns with A-form RNA helices. In contrast, C2'-endo (South) puckering is minor in ribonucleotides like CMP but more common in deoxy forms. The phosphate backbone exhibits flexibility around the P-O5'-C5'-C4' torsion (γ), allowing gauche⁺ (≈60°) and trans (≈180°) rotamers, with gauche preferred to minimize steric clashes. Nuclear magnetic resonance (NMR) studies in reveal dynamic ensembles where CMP maintains an average /C3'-endo conformation, with coupling constants (³J_{H1'-H2'} ≈ 5-6 Hz and ³J_{H2'-H3'} ≈ 5 Hz) consistent with a conformational between North and puckers. Space-filling models derived from crystal structures (e.g., PDB entries with CMP s) depict a compact overall shape, approximately 10 in length, with the extended base (planar and aromatic) stacked perpendicular to the ribofuranose ring and the pendant phosphate projecting outward for ionic interactions. Environmental factors modulate CMP conformation; at low pH (below 4), protonation of the N3 site in shifts the glycosidic torsion toward (χ ≈ 0°-90°), as evidenced by UV , potentially disrupting base pairing. Solvent polarity influences sugar puckering, with polar protic s like stabilizing the C3'-endo form through hydrogen bonding to the 2'-OH, while nonpolar environments may favor C2'-endo. These shifts underscore the role of cellular conditions in fine-tuning CMP's structural adaptability for helix formation.

Biosynthesis

De Novo Pathway

The de novo biosynthesis of cytidine monophosphate (CMP) occurs as part of the pyrimidine nucleotide synthesis pathway, which assembles the pyrimidine ring from simple precursors such as aspartate, , bicarbonate, and 5-phosphoribosyl-1-pyrophosphate (PRPP), ultimately yielding (UMP) as the first committed nucleotide product. UMP is then converted to CMP through sequential to uridine triphosphate (UTP) and to (CTP), followed by . This pathway ensures the cell's supply of pyrimidines for synthesis without relying on preformed bases or nucleosides. The core steps leading to UMP are catalyzed by a series of enzymes, beginning with the multifunctional CAD complex—a hexameric protein comprising carbamoyl-phosphate synthetase II (CPSII), aspartate transcarbamoylase (ATCase), and dihydroorotase (DHOase). CPSII condenses , , and two ATP molecules to form ; ATCase then transfers the carbamoyl moiety to aspartate, yielding N-carbamoyl-L-aspartate; and DHOase cyclizes this intermediate to L-dihydroorotate. Dihydroorotate is oxidized to orotate by the flavin-dependent (DHODH), an enzyme anchored to the in eukaryotes. Orotate subsequently combines with PRPP via orotate phosphoribosyltransferase (OPRT) to produce orotidine 5'-monophosphate (OMP), which is decarboxylated by OMP decarboxylase (ODCase) to generate UMP; OPRT and ODCase form a bifunctional UMP synthase in mammals. Conversion of UMP to CMP proceeds through kinase-mediated phosphorylations: UMP is first converted to UDP by UMP/CMP kinase, then to UTP by using ATP. CTP synthetase then catalyzes the ATP- and glutamine-dependent amination of UTP at the C4 position of the uracil ring, producing CTP as the direct precursor to CMP. CTP is dephosphorylated in two steps—first to CDP by nucleoside triphosphate pyrophosphohydrolase (e.g., apyrase-like enzymes) and then to CMP by nonspecific phosphatases—to maintain nucleotide pools for various cellular needs. Regulation of the de novo pathway occurs primarily at CPSII within the CAD complex, where CTP exerts allosteric feedback inhibition to prevent overproduction of , while PRPP acts as an activator. Additional involves of CAD by kinases such as and MAPK, enhancing activity during . In eukaryotes, the pathway is mostly cytosolic, with CAD and UMP synthase in the and (the latter during ), except for the mitochondrial localization of DHODH, which links pyrimidine synthesis to .

Salvage Pathway

The salvage pathway for cytidine monophosphate (CMP) enables the recycling of pre-existing nucleosides and bases into s, circumventing the more energy-demanding route. This process is particularly vital in tissues exhibiting high rates of turnover, such as the liver and intestine, where it supports efficient maintenance of cellular pools for synthesis and other metabolic needs. By reutilizing components from degraded nucleic acids or external sources, the pathway conserves (PRPP) and ATP, providing a rapid response to fluctuating demands when activity is insufficient. The primary route in this pathway converts directly to CMP through . The uridine-cytidine kinase 2 (UCK2), often the rate-limiting step, catalyzes the reaction: + ATP → CMP + , with UCK1 providing complementary activity. UCK2, a homotetrameric , achieves specificity via hydrogen bonding interactions at residues His117 and Tyr112 with 's 4-amino group, while a magnesium cofactor facilitates transfer. Substrates like originate from dietary intake, turnover within cells, or contributions from gut microbial flora, entering cells via nucleoside transporters such as hENT1 and hENT2. Direct salvage from the base is not significant in mammals, as mammalian tissues lack cytosine phosphoribosyltransferase and cytosine deaminase activities. In contrast, such base salvage routes are more prominent in certain microorganisms. Instead, any cytosine would require conversion via other pathways, but salvage in mammals primarily occurs at the nucleoside level. Regulation of the pathway occurs primarily at the level of UCK enzyme stability and activity, with UCK2 expression and half-life modulated by signaling to match cellular growth states. Feedback inhibition by downstream products like (CTP) and uridine triphosphate (UTP) prevents overaccumulation, while the pathway activates under conditions of low flux. Notably, UCK2 exhibits broader substrate tolerance, also phosphorylating deoxycytidine and deoxyuridine to their monophosphates, aiding deoxyribonucleotide salvage. Evolutionarily, this pathway confers an energy-conserving advantage by recycling abundant , reducing reliance on - and aspartate-intensive steps, which is especially beneficial in nutrient-limited environments. Defects in salvage enzymes, such as UCK2 mutations or inhibition, result in intermediate accumulation, replication stress, and heightened sensitivity to nucleoside analogs in clinical contexts like cancer therapy. When salvage substrates are scarce, cells may integrate this route with for balanced CMP production.

Metabolism

Anabolic Pathways

Cytidine monophosphate (CMP) functions as a key precursor in anabolic pathways, where it undergoes sequential to generate cytidine diphosphate (CDP) and cytidine triphosphate (CTP), providing high-energy s for synthesis, membrane formation, and processes. These activation steps occur primarily through salvage mechanisms, utilizing ATP as the donor to elevate the energy state of the nucleotide for downstream biosynthetic incorporation. The first phosphorylation step converts CMP to CDP and is catalyzed by cytidylate kinase (EC 2.7.4.14), with two distinct isoforms in cells: the cytosolic UMP/CMP kinase 1 (CMPK1) and the mitochondrial UMP/CMP kinase 2 (CMPK2). CMPK1, a bifunctional , efficiently transfers the γ-phosphate from ATP to CMP (or UMP) in the CMP + ATP → CDP + , supporting general pools in the and . CMPK2 performs an analogous in the , CMP + ATP → CDP + , but is specialized for local supply within mitochondria. Subsequent conversion of CDP to CTP is mediated by nucleoside diphosphate kinases (NDPKs), a family of enzymes encoded by the genes (NME1–NME9 in humans), which catalyze the reversible phosphotransfer CDP + ATP ⇌ CTP + . These hexameric proteins exhibit broad substrate specificity, preferentially phosphorylating CDP among diphosphates, and are essential for equilibrating pools across cellular compartments. CMPK2 holds particular significance in mitochondrial anabolic processes, where it sustains CDP levels for deoxynucleotide triphosphate (dNTP) synthesis required for (mtDNA) replication and repair, thereby maintaining mitochondrial genome stability and efficiency. Dysregulation of CMPK2 leads to mtDNA depletion and elevated , underscoring its role in mitochondrial homeostasis. Additionally, CMPK2 contributes to antiviral defense by bolstering nucleotide availability that restricts , independent of or in concert with signaling. Regulation of these anabolic steps emphasizes transcriptional control, particularly for CMPK2, which is induced as an (ISG) through the JAK-STAT pathway in response to type I interferons, enhancing its expression during innate immune activation against pathogens like and coronaviruses. CMPK1 operates more constitutively to meet basal demands, with overall pathway flux influenced by cellular ATP availability and pool balances rather than direct allosteric feedback from CTP on the kinases themselves. The anabolic progression from CMP remains largely confined to the cytidine lineage, with minimal direct interconversion to uridine counterparts like at the monophosphate stage.

Catabolic Pathways

The of cytidine monophosphate (CMP) involves a series of enzymatic reactions that dismantle the to its , , and components, preventing cellular accumulation and enabling through salvage pathways to maintain and balance. This process begins in the and proceeds through followed by deglycosylation and base degradation, with products such as uracil and ribose-1-phosphate feeding back into salvage mechanisms for reuse. The initial step is the dephosphorylation of CMP to cytidine and inorganic (Pi), catalyzed by cytosolic 5'-nucleotidases such as NT5C2, which exhibit broad specificity for ribonucleoside monophosphates. This reaction occurs primarily in the , though surface ecto-5'-nucleotidase () can contribute in extracellular contexts. Subsequent deglycosylation of cytidine is mediated by cytidine deaminase (), which hydrolyzes cytidine to and (NH₃) in an irreversible reaction essential for pyrimidine salvage and . is then cleaved by uridine phosphorylase 1 (UPP1) into uracil and ribose-1-phosphate via phosphorolysis, a reversible step that supports recycling. Further breakdown of uracil occurs through the action of dihydropyrimidine (DPYD), the rate-limiting enzyme that reduces uracil to dihydrouracil, ultimately yielding β-alanine and CO₂ in a multi-step process. Meanwhile, ribose-1-phosphate is converted to ribose-5-phosphate by phosphopentomutase (PGM2), which integrates the sugar into central metabolic pathways like the pentose phosphate route. Pyrimidine catabolic pathways, including CMP degradation, are upregulated during catabolic states such as or tissue breakdown to manage turnover. Polymorphisms in the gene, such as the 79A>C variant, influence activity and are associated with altered metabolism, leading to increased drug toxicity in affected individuals. End products like and (NH₄⁺) are primarily excreted via urine, while mitochondrial pools may link to through enzymes like CMP kinase 2 (CMPK2), which modulates CMP levels for mtDNA .

Biological Functions

Role in Nucleic Acid Synthesis

Cytidine monophosphate (CMP) serves as a precursor that is phosphorylated to (CTP), which acts as a fundamental building block in synthesis. During transcription, incorporates CTP into the growing RNA chain, where the cytidine base pairs with in the DNA template through three hydrogen bonds: the N3 of bonds to N1 of guanine, the O2 of cytosine to the N2 amino group of guanine, and the N4 amino group of cytosine to the O6 of guanine. This base-pairing specificity ensures accurate sequence complementarity in RNA production. The polymerization process involves the nucleotidyl transfer reaction catalyzed by RNA polymerases, such as and III in eukaryotes, where CTP reacts with the 3'-hydroxyl end of the growing chain (ppRNA) to form a : CTP + ppRNA → CMP-RNA + (PPi). This reaction maintains high fidelity through mechanisms including base-pairing selection and , where mismatched incorporations are corrected via and cleavage by the polymerase's intrinsic RNase activity. CMP itself is not directly incorporated but must first be activated to CTP by UMP/CMP and . In various RNA types, cytidine residues derived from CTP play critical roles; in transfer RNA (tRNA), they are essential components of anticodon loops for codon-anticodon recognition during , while in messenger RNA (mRNA), they contribute to codon sequences and splicing signals, such as in branch point recognition motifs like UACUAAC. In ribosomal RNA (rRNA), cytidine residues support structural stability and functional domains necessary for assembly and protein synthesis. Unlike in RNA, CMP does not contribute directly to ; instead, the deoxy form dCTP is produced via reduction of CDP to dCDP by , followed by . In many organisms, constitutes approximately 25% of bases, reflecting typical levels, and isotopic labeling studies demonstrate rapid turnover of molecules, with half-lives ranging from minutes for mRNA to hours or days for rRNA and tRNA, highlighting the dynamic nature of synthesis. Errors in cytidine incorporation can occur through , converting cytidine to (CMP to UMP equivalent in ), mediated by family enzymes during , which alters codon specificity and without changing the genomic sequence.

Role in Glycosylation and Other Processes

Cytidine monophosphate (CMP) serves as a critical activated donor in pathways, particularly through its conversion to CMP-N-acetylneuraminic acid (CMP-Neu5Ac), the activated form of . This activation occurs via CMP-Neu5Ac synthetase (CMAS), which catalyzes the reaction between CTP and (Neu5Ac) in the or , depending on the organism. The resulting CMP-Neu5Ac is transported to the Golgi apparatus, where it acts as the sugar donor for sialyltransferases that incorporate onto glycoproteins and glycolipids. For instance, sialyltransferases such as ST6Gal-I transfer from CMP-Neu5Ac to N-linked glycans on glycoproteins like mucins, influencing their stability and function, while other sialyltransferases add to gangliosides, complex glycolipids essential for neural cell recognition. In , CMP-Neu5Ac similarly supports sialylation of components, including lipopolysaccharides and capsules, aiding in immune evasion and structural integrity. Sialylation processes are evolutionarily conserved but unique to among eukaryotes, with the full pathway emerging in deuterostomes; independently acquired CMP-Neu5Ac synthetases for similar purposes. Beyond glycosylation, CMP participates in lipid metabolism through its role in generating cytidine diphosphate (CDP) intermediates. CMP is phosphorylated by cytidylate kinases to CDP, which is further utilized in the synthesis of CDP-diacylglycerol (CDP-DAG) by CDP-DAG synthase, using CTP and phosphatidic acid as precursors. CDP-DAG serves as a branch point for phospholipid biosynthesis, including phosphatidylinositol and cardiolipin, which are vital for membrane integrity. In the Kennedy pathway for phosphatidylcholine synthesis, CMP contributes indirectly via the nucleotide pool to form CDP-choline from phosphocholine and CTP, which then reacts with diacylglycerol to produce phosphatidylcholine, a major membrane lipid regulating lipid droplet formation and cellular growth. CMP also plays a minor role in coenzyme A (CoA) biosynthesis, where cytidine nucleotides support the CTP-dependent formation of phosphopantothenoylcysteine, an intermediate in the pantothenate pathway essential for acyl carrier functions in fatty acid metabolism. In cellular signaling, CMP is phosphorylated by cytidine monophosphate 2 (CMPK2), a that maintains nucleotide triphosphate pools for replication and repair. CMPK2-mediated of CMP to CDP enhances (ROS) production, linking to innate immune responses; during viral infections, CMPK2 activation promotes type I (IFN) production through IFN-dependent and independent pathways, including cGAS-STING signaling and activation. This process is conserved across vertebrates, with CMPK2 ensuring availability for mtDNA maintenance in post-mitotic cells. CMP-Neu5Ac levels further regulate cellular processes, with fluctuations modulating sialylation extent to influence and ; elevated CMP-Neu5Ac enhances sialyltransferase activity, promoting migratory phenotypes in cancer cells via altered interactions, while depletion impairs adhesion in neural development.

Physiological and Clinical Significance

In Human Health

Cytidine monophosphate (CMP) is integral to maintaining nucleotide in human cells, where it balances synthesis and degradation to support production and metabolic stability. Intracellular CMP concentrations reflect tight regulation that prevents imbalances in pyrimidine pools essential for cellular function. This is achieved through coordinated anabolic and catabolic processes, including phosphatase-mediated of CMP to nucleosides for or excretion. In human development, CMP contributes to fetal RNA synthesis and glycosylation pathways, particularly by activating sialic acid into CMP-sialic acid, a key donor for sialoglycans that facilitate neural tissue formation and neuronal network maturation. During embryogenesis, sialylation patterns involving CMP-sialic acid are dynamically regulated to promote brain development, with deficiencies potentially disrupting polysialic acid structures critical for synaptic plasticity and cognitive growth. Maternal sialic acid supplementation, which relies on CMP activation, has been shown to enhance offspring brain sialic acid content and cognitive outcomes, underscoring CMP's role in prenatal neural health. Nutritionally, CMP can be supported via the salvage pathway using dietary from RNA-rich sources such as extracts and organ meats, which provide for endogenous replenishment. further aids CMP availability, as human milk contains significant levels of CMP among its , with concentrations varying by stage but consistently supporting metabolic needs. These dietary inputs help sustain CMP pools during periods of high demand, such as rapid growth. Aging is associated with mitochondrial dysfunction that may involve impaired CMP-related pathways, as loss of cytidylate 2 (CMPK2)—which phosphorylates CMP—leads to reduced mitochondrial integrity and energy production. In , nucleotide deficiencies, including low CMP availability, compromise immune function by limiting RNA synthesis for immune and production. Urinary , a degradation product of CMP, serves as a for RNA turnover rates, with elevated levels indicating increased cellular degradation often linked to metabolic stress. Sex and gender differences influence CMP-dependent , particularly in , where hormones like regulate sialylation patterns on glycoproteins to modulate ovarian function and implantation. and progesterone fluctuations during the and alter CMP-sialic acid utilization, enhancing sialoglycan expression on reproductive tissues to support fertility and at the maternal-fetal interface.

Medical Applications and Disorders

Orotic aciduria, also known as hereditary orotic aciduria, results from defects in synthase (UMPS), which impairs biosynthesis and leads to reduced levels of UMP and downstream nucleotides including CMP. This deficiency manifests as , growth retardation, and orotic acid due to the accumulation of orotic acid, with or uridine triacetate supplementation used therapeutically to bypass the enzymatic block and restore pools. Cytidine deaminase () deficiency is a rare autosomal recessive disorder that causes through the toxic accumulation of deoxycytidine and its metabolites, which inhibit proliferation and . Affected individuals present with recurrent infections, , and profoundly low T-cell counts, highlighting CDA's role in pyrimidine salvage to prevent imbalances that disrupt immune cell development. Mutations in the CMPK2 gene, encoding / kinase 2, are linked to mitochondrial dysfunction and familial brain calcification, leading to energy deficits. CMPK2 upregulation promotes progression in by enhancing mitochondrial metabolism and antiviral signaling, while its role in restricting (HCV) replication underscores its involvement in viral resistance pathways. Loss-of-function variants exacerbate in conditions like acute via dysregulated cGAS-STING activation. Deficiency in thymidine phosphorylase (TYMP), which catalyzes the reversible phosphorolysis of nucleosides, results in elevated levels of and deoxyuridine, contributing to neurological disorders such as mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) through toxic imbalances. This salvage pathway disruption leads to demyelination, gastrointestinal dysmotility, and . CMP plays a role in chemotherapy resistance, particularly in leukemias, where altered salvage kinase activity reduces the activation of analogs, allowing cancer cells to evade DNA damage. Therapeutically, cytarabine (Ara-C), a CMP analog, is activated via to Ara-CMP by deoxycytidine and further by CMP kinase, incorporating into DNA to inhibit and treat . , another analog, relies on CMP kinase (CMPK1) for conversion to its diphosphate form, which inhibits and in pancreatic and other solid tumors. In , defects in CMP-sialic acid synthetase impair activation for , leading to muscle degeneration; supplementation serves as a therapeutic strategy to restore CMP-Neu5Ac levels and alleviate symptoms in GNE .

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