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However, when HepaRG stem-cell derived human hepatocytes were subjected to APAP, the same mechanisms of hepatotoxicity were demonstratedstarting with GSH depletion and moving through protein adduct formation, superoxide and peroxynitrite formation and lysosomal iron uptake into mitochondria.911,13,14 Oxidative stress compounded with lysosomal iron uptake within the mitochondria leads to mitochondrial membrane dysfunction via disruption of the mitochondrial membrane permeability transition pore, triggering cell necrosis.911,13,14 Organelle swelling leads to cellular necrosis and the release of mitochondrial contents, such as apoptosis-inducing factor (AIF) and endonuclease G (EndoG), which in turn migrate to the nuclei and cause DNA fragmentation.12 Cellular swelling, karyolysis, karyorrhexis, vacuolization, inflammation and release of cellular contents (alanine aminotransferase, ALT) are key processes of hepatocyte necrosis and related death in humans, as shown by the biochemical evidence of severe elevations in aminotransferases, especially ALT.911 In non-toxic ingestion of APAP, the processing of NAPQI occurs with rapid conjugation by hepatic GSH to form non-toxic mercaptate and cysteine compounds that are excreted in urine.8 The body requires a delicate balance between production and detoxification/transport of harmful reactive species and protein adducts, and when these defenses are overwhelmed at hepatotoxic doses of APAP, the glucoronidation and sulfonation pathways become saturated, pushing the majority of APAP to be metabolized to NAPQI by the CYP 2E1 pathway and resulting in GSH depletion and build-up of toxic NAPQI.9,10 Myeloperoxidase and cyclooxygenase-1 are enzymes that also function in the processing of NAPQI into non-reactive metabolites

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