[16, 58] Specific gene knockout models provided additional evidence for a role of oxidant stress. For example, metallothionein Saracatinib mouse (MTI/MTII)-null mice were more sensitive to INH/rifampicin treatment than wild-type mice, suggesting that the presence of the cysteine-rich metallothionein

provided some protection against oxidant stress caused by this cotreatment.[59] However, none of these rodent models was able to recapitulate the overt liver injury encountered in exposed patients. Alternatively, there is evidence that INH can impair the anti-oxidant defense. For example, one key regulator of the adaptive anti-oxidant response to cellular oxidant stress is the transcription factor Nrf2.

Nrf2 acts by binding to anti-oxidant response elements (AREs) in the promoter region of target genes including heme oxygenase-1 and NAD(P)H quinone oxidoreductase 1. A recent study has revealed that INH, at noncytotoxic concentrations, caused a marked concentration-dependent inhibition of ARE-mediated anti-oxidant gene expression, both at basal conditions and after a pro-oxidant challenge, in a number of cell types including HepG2 cells.[60] To what extent such a mechanism could be involved in INH-induced DILI is currently not known. Mitochondrial dysfunction is a major mode of toxicity by which a large number of different drugs can cause liver injury by a number of distinct mechanisms.[61, 62] Mitochondrial toxicity can include direct effects of drugs on energy homeostasis or increased pro-oxidant stress, which often activates mitochondria-mediated cell death pathways Dactolisib including mitophagy or permeabilization of the outer and/or inner mitochondrial membrane, MCE which results in caspase-dependent or -independent cell death. For INH, mitochondria have been implicated in contributing to hepatocyte injury, too, and there is evidence that it is hydrazine, again, which interferes with mitochondrial function. For example, after treatment of cultured primary rat hepatocytes or rat liver cell lines with hydrazine (0.5–5 mM) 22 h, the cells

had developed megamitochondria.[63] The occurrence of these abnormally large mitochondria preceded the induction of apoptosis, and they were considered to reflect adaptive responses to oxidant stress and/or decreased oxygen consumption rates. With regards to a mechanistic explanation, earlier studies had found that in cultured rat hepatocytes exposed to hydrazine, the activity of succinate dehydrogenase was inhibited in a concentration-dependent manner.[41] While this suggests an effect of hydrazine on complex II and/or the TCA cycle, it was not clear whether the apparent inhibitory effect was due to a direct interaction with the enzyme complex or rather a consequence of cofactor or substrate depletion.