serum acute phase reactants hallmark healthy individuals at risk for acetaminophen-induced liver injury

background: acetaminophen (apap) is a commonly used analgesic. however, its use is associated with drug-inducedliver injury (dili). it is a prominent cause of acute liver failure, with apap hepatotoxicity far exceeding other causes ofacute liver failure in the united states. in order to improve its safe use this study aimed to identify individuals at riskfor dili prior to drug treatment by searching for non-genetic serum markers in healthy subjects susceptible toapap-induced liver injury (aili). methods: healthy volunteers (n = 36) received either placebo or acetaminophen at the maximum daily dose of 4 gfor 7 days. blood samples were taken prior to and after apap treatment. serum proteomic profiling was done by2d sds-page and matrix-assisted laser desorption/ionization-time of flight-mass spectrometry. additionally, theproteins c-reactive protein, haptoglobin and hemopexin were studied by quantitative immunoassays. results: one-third of study subjects presented more than four-fold increased alanine transaminase activity toevidence liver injury, while serum proteomics informed on 20 proteins as significantly regulated. these functionprimarily in acute phase and immune response. pre-treatment associations included c-reactive protein,haptoglobin isoforms and retinol binding protein being up to six-fold higher in aili susceptible individuals,whereas alpha1-antitrypsin, serum amyloid a, kininogen and transtyretin were regulated by nearly five-fold in ailiresponders. when compared with published findings for steatohepatitis and cases of hepatocellular, cholestaticand mixed dili, 10 proteins were identified as uniquely associated with risk for aili, including plasminogen. notably, this zymogen facilitates macrophage chemotactic migration and inflammatory response as reported forplasminogen-deficient mice shown to be resistant to apap hepatotoxicity. finally, analysis of a publicly availabledatabase of gene expression profiles of cultures of human hepatocytes treated with drugs labeled as no- (n = 8), low- (n = 45) or most-dili-concern (n = 39) confirmed regulation of the identified biomarkers to demonstrate utilityin predicting risk for liver injury. conclusions: the significant regulation of acute phase reactants points to an important link between aili and theimmune system. monitoring of serum acute phase reactants prior to drug treatment may contribute to preventionand management of aili, and may also be of utility for other drugs with known liver liabilities.