Drug-Induced Liver Injury Module

Toxicology Pharmacology Module drug_induced_liver_injury 2 disorders Pathograph 11

A conserved treatment-toxicity module representing the final common pathway by which hepatotoxic drugs injure and kill hepatocytes. The culprit agent and the proximal trigger vary — dose-dependent reactive-metabolite formation (the acetaminophen/NAPQI archetype), bile salt export pump (BSEP) inhibition and cholestatic stress, or idiosyncratic immune-mediated injury — but the downstream sequence repeatedly converges on mitochondrial dysfunction and oxidative stress, hepatocyte cell death (necrosis and apoptosis), sterile/immune inflammatory amplification, and clinically apparent liver injury that can progress to acute liver failure. This is a "side effect as mechanism" module: it captures the adverse-drug-reaction pathophysiology shared across many hepatotoxic drugs, so a drug-toxicity entry can declare conformance rather than re-deriving the chain.

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Pathophysiology Nodes

5 shared nodes are defined in this module.

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Cell Types

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Biological Processes

xenobiotic metabolic process GO:0006805 ↑ INCREASED response to oxidative stress GO:0006979 ↑ INCREASED cell death GO:0008219 ↑ INCREASED apoptotic process GO:0006915 ↑ INCREASED inflammatory response GO:0006954 ↑ INCREASED T cell mediated immunity GO:0002456 ↑ INCREASED

Notes

This is a mechanism module, not a specific disease. Disorder entries reference individual nodes via conforms_to (e.g., "drug_induced_liver_injury#Hepatocyte Cell Death"). Conforming nodes should substitute the disorder-specific hepatotoxic driver (the particular drug and its proximal mechanism — reactive metabolite, BSEP inhibition, or immune-mediated idiosyncratic injury) while preserving the conserved metabolite/stress → mitochondrial dysfunction → hepatocyte death → inflammation → liver injury chain. The key conformance / central-effector target is "drug_induced_liver_injury#Hepatocyte Cell Death".

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Experimental Models

Human quad-culture Liver-Chip (Emulate/Wyss) for predictive hepatotoxicology ORGAN_ON_CHIP namo:OrganOnChip

Microfluidic dual-channel human Liver-Chip populated with primary hepatocytes plus the three non-parenchymal liver cell types (liver sinusoidal endothelial cells, Kupffer cells, stellate cells) under continuous flow. A non-animal New Approach Methodology qualified against Innovation and Quality consortium criteria on a blinded benchmark drug set, with albumin synthesis, ALT release, morphological injury scoring, caspase 3/7 and TMRM mitochondrial imaging as readouts of the conserved DILI cascade.

Organism

human NCBITaxon:9606

Tissue

liver UBERON:0002107

Cell source

Primary human hepatocytes from multiple donors co-cultured with human liver sinusoidal endothelial cells, Kupffer cells, and stellate cells

Culture

Microfluidic dual-channel liver organ-chip under continuous perfusion

Publication

PMID:36473994

Pathograph links

Mitochondrial Dysfunction and Oxidative Stress Mitochondrial injury is imaged directly in the chip as loss of TMRM accumulation in hepatocytes exposed to hepatotoxicants.

Hepatocyte Cell Death Hepatocyte toxicity is quantified by loss of albumin synthesis, ALT release, morphological injury scoring, and caspase 3/7 apoptosis imaging.

Liver Injury and Acute Liver Failure Provides a human, non-animal prediction of clinical drug-induced liver injury liability across a blinded benchmark drug set.

Findings

The human Liver-Chip predicted drug-induced liver injury across a blinded 27-drug benchmark set with 87% sensitivity and 100% specificity.

Evidence: 1

All seven toxic drugs reduced albumin production or increased ALT or injury-morphology scores at clinically bracketed concentration multiples.

Evidence: 1

Ingber (Wyss Institute) is a co-author; this is the systematic qualification study for the liver organ-chip platform highlighted in the NAMeRS 2026 summit multi-organ-chip case study.

Evidence: 1

Curio Barrier Liver Chip with iPSC-derived human liver organoids ORGAN_ON_CHIP namo:OrganOnChip

High-throughput microfluidic liver-on-a-chip (8 x 2 well "Curiochip" configuration) hosting three-dimensional liver organoids differentiated from human induced pluripotent stem cells. Sustains albumin secretion and cytochrome P450 activity for 28 days, enabling prolonged-exposure hepatotoxicity testing without primary human hepatocytes or animals.

Organism

human NCBITaxon:9606

Tissue

liver UBERON:0002107

Cell source

Human induced pluripotent stem cell-derived liver organoids (also generated by in situ differentiation of foregut spheroids on chip)

Culture

High-throughput microfluidic liver chip with 3D organoid culture

Publication

PMID:39529647

Pathograph links

Reactive Drug Metabolite Formation and Hepatocellular Stress Retained cytochrome P450 activity over 28 days supports drug bioactivation, the proximal trigger of the module.

Hepatocyte Cell Death Detects acetaminophen- and fialuridine-induced hepatocyte injury at micromolar rather than millimolar concentrations.

Findings

iPSC-derived liver organoids on chip detect acetaminophen and fialuridine hepatotoxicity at micromolar concentrations.

Evidence: 1

The chips retain liver-specific function (albumin secretion, cytochrome P450 activity) and DILI responsiveness for 28 days, enabling prolonged-exposure idiosyncratic DILI modeling.

Evidence: 2

Directly relevant to the NAMeRS 2026 summit project on 3D iPSC-hepatocyte models for gene-therapy liver safety; the model is fully human and animal-free.

Evidence: 1

Autologous HLA-genotyped liver organoid-CD8 T cell co-culture microarray CO_CULTURE namo:Organoid

Matrix-free human liver organoid microarray co-cultured with autologous CD8-positive T cells derived from the same HLA-genotyped induced pluripotent stem cell donor. Reconstitutes antigen-specific adaptive immunity alongside hepatocytes, the component conventional hepatotoxicity models lack, and models idiosyncratic DILI in a genetically defined host context.

Organism

human NCBITaxon:9606

Tissue

liver UBERON:0002107

Cell source

HLA-genotyped iPSC-derived human liver organoids with autologous iPSC-derived CD8-positive T cells

Culture

Matrix-free liver organoid microarray with autologous T cell co-culture

Publication

PMID:41001778

Pathograph links

Sterile and Immune-Mediated Inflammatory Amplification Reconstitutes the HLA-restricted adaptive-immune arm of the amplifier node, with cytotoxic mediator secretion and hepatocyte injury readouts.

Hepatocyte Cell Death T cell-mediated hepatocyte apoptosis and cytokeratin-18 release measure the central effector step under immune attack.

Findings

Autologous organoid-T cell co-culture reproduces flucloxacillin idiosyncratic DILI in HLA-B*57:01 carriers.

Evidence: 1

The co-culture captures adaptive immune-mediated hepatotoxicity readouts (TNF-alpha, granzyme B, cytokeratin-18 release).

Evidence: 1

Conventional hepatotoxicity models lack the components needed to capture patient-specific, T cell-mediated liver injury.

Evidence: 1

Akura Twin 384-well liver fibrosis microphysiological system (HepaRG/THP-1 and hTERT-HSC microtissues) CO_CULTURE namo:CoCulture

High-throughput microphysiological system built on a 384-well microplate of 168 interconnected well pairs. HepaRG hepatocyte microtissues, with or without THP-1 monocytic cells, occupy the alpha well of each pair and hepatic stellate cell (hTERT-HSC) microtissues occupy the beta well. A non-animal New Approach Methodology in which methotrexate and acetaminophen are used as hepatotoxicant challenges alongside TGF-beta 1, with albumin synthesis and glucose/lactate sensing as cell-health readouts.

Organism

human NCBITaxon:9606

Tissue

liver UBERON:0002107

Cell source

Established human cell lines throughout - HepaRG hepatocyte-like cells, hTERT-immortalized hepatic stellate cells, and THP-1 monocytic cells.

Culture

384-well Akura Twin microplate of 168 interconnected well pairs carrying 3D microtissues, with glucose and lactate sensors monitoring cell health

Publication

PMID:40754287

Pathograph links

Hepatocyte Cell Death perturbs fidelity: moderate Methotrexate and acetaminophen are applied as chemical challenges to the hepatocyte compartment, driving it toward this node and allowing the approach to it to be quantified.

Limitations: Only loss of albumin synthesis is reported. The abstract describes no direct death assay - no caspase activation, LDH release or viability measurement - so the model perturbs the hepatocyte toward death without demonstrating that death occurred. HepaRG cells also carry a different drug-metabolizing enzyme profile from primary human hepatocytes, which matters for acetaminophen in particular.

Readouts

Albumin production under methotrexate and acetaminophen challenge

Direction: DECREASED

Interpretation: Falling albumin synthesis after hepatotoxicant exposure is the model's index of hepatocellular injury preceding death.

Evidence: 1

Sterile and Immune-Mediated Inflammatory Amplification partially recapitulates fidelity: low A monocytic compartment co-cultured with the hepatocyte microtissues supplies the innate immune arm of this node, and shifts to an activated, profibrogenic state that is measurable alongside hepatocyte injury.

Limitations: The activation reported in the abstract is driven by exogenous TGF-beta 1, not by methotrexate or acetaminophen, so the drug-to-inflammation step central to this node is not itself demonstrated. THP-1 is a circulating monocytic leukemia line rather than a resident Kupffer cell, and there is no sinusoidal endothelial or lymphocyte compartment.

Readouts

THP-1 activation marker expression (ALOX5AP, TREM2, TGF-beta 1)

Direction: INCREASED

Interpretation: Induction of these transcripts marks the monocytic compartment entering an activated state within the liver co-culture.

Evidence: 1

PAI-1 protein in hepatocyte-monocyte co-culture

Direction: INCREASED

Interpretation: PAI-1 rose most where the monocytic compartment was present, evidencing an amplifying hepatocyte-monocyte interaction rather than a hepatocyte response alone.

Evidence: 1

Recorded here for its methotrexate and acetaminophen challenge arms. The same system is curated on Liver_Cirrhosis for the fibrosis arm - stellate activation, matrix output and TGF-beta perturbation - which is where the paper's primary claim sits.

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Used By Disorder Entries

Acetaminophen Hepatotoxicity via NAPQI Formation, Protein Adduction, and Glutathione Depletion → Reactive Drug Metabolite Formation and Hepatocellular Stress , Mitochondrial Oxidant Stress and JNK Amplification → Mitochondrial Dysfunction and Oxidative Stress , Centrilobular Oncotic Hepatocyte Necrosis → Hepatocyte Cell Death , Acetaminophen-Induced Acute Liver Injury and Failure → Liver Injury and Acute Liver Failure

Isoniazid Toxicity via Hepatic Bioactivation of Isoniazid → Reactive Drug Metabolite Formation and Hepatocellular Stress , Hepatocyte Injury and Death → Hepatocyte Cell Death , Immune-Mediated Amplification of Hepatic Injury → Sterile and Immune-Mediated Inflammatory Amplification , Isoniazid-Induced Liver Injury → Liver Injury and Acute Liver Failure

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Pathograph

Use the checkboxes to hide or show graph categories. Hover nodes for evidence-backed metadata.

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Pathophysiology

Reactive Drug Metabolite Formation and Hepatocellular Stress

trigger

The conserved initiating lesion is hepatic handling of the drug producing a proximal toxic stimulus: bioactivation to a reactive metabolite (the acetaminophen → NAPQI archetype), inhibition of the bile salt export pump with cholestatic accumulation, or covalent/oxidative stress on hepatocyte macromolecules. Hepatocytes, the principal site of xenobiotic metabolism, bear the brunt of this stress regardless of the specific drug.

hepatocyte CL:0000182

xenobiotic metabolic process GO:0006805 ↑ INCREASED

Used by disorders

Acetaminophen Hepatotoxicity as NAPQI Formation, Protein Adduction, and Glutathione Depletion

Isoniazid Toxicity as Hepatic Bioactivation of Isoniazid

Downstream

Mitochondrial Dysfunction and Oxidative Stress Reactive metabolites and cholestatic stress converge on mitochondrial injury and oxidant production.

Show evidence (2 references)

PMID:36670547 SUPPORT Other

"APAP-induced hepatotoxicity (AIH) is mainly caused by the toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI)"

Establishes reactive-metabolite formation (the archetypal NAPQI mechanism) as the proximal trigger of hepatotoxicity captured by this node. Evidence source is OTHER because this is a review article.

PMID:32511920 SUPPORT Other

"In vitro assays to assess inhibition of the bile salt export pump (BSEP), mitotoxicity, reactive metabolite (RM) formation, and hepatocyte cytolethality"

Enumerates the conserved proximal DILI mechanisms — BSEP inhibition, mitotoxicity, and reactive-metabolite formation — that this insult-agnostic trigger node represents. Evidence source is OTHER because this is a review.

Mitochondrial Dysfunction and Oxidative Stress

amplifier

Reactive metabolites and accumulated bile acids damage mitochondria, the organelle most central to hepatocyte bioenergetics, producing oxidative stress, impaired ATP synthesis, and mitochondrial permeability transition. This is the major amplifying event linking the proximal drug stress to hepatocyte death across hepatotoxic agents.

hepatocyte CL:0000182

response to oxidative stress GO:0006979 ↑ INCREASED

mitochondrion GO:0005739

Used by disorders

Acetaminophen Hepatotoxicity as Mitochondrial Oxidant Stress and JNK Amplification

Downstream

Hepatocyte Cell Death Mitochondrial failure and oxidative stress precipitate hepatocyte necrosis and apoptosis.

Show evidence (3 references)

PMID:36670547 SUPPORT Other

"Mitochondrial oxidative stress and dysfunction are the major cellular events associated with APAP-induced liver injury."

Identifies mitochondrial oxidative stress and dysfunction as the major cellular events driving hepatotoxic injury, the amplifier step of this module. Evidence source is OTHER because this is a review article.

PMID:34485975 SUPPORT Other

"Hepatocytes are highly metabolic cells which have abundant mitochondria suggesting a biologically relevant role for mitochondrial dynamics in hepatocyte injury and recovery."

Establishes the central role of mitochondria in hepatocyte injury and recovery, supporting mitochondrial dysfunction as a conserved DILI mechanism. Evidence source is OTHER because this is a review article.

PMID:36473994 SUPPORT In Vitro

"mitochondrial injury measured by visualizing reduction of tetramethylrhodamine methyl ester (TMRM) accumulation"

New Approach Methodology (NAM) evidence: in a human quad-culture Liver-Chip challenged with known hepatotoxicants, mitochondrial injury was directly imaged as loss of TMRM accumulation, giving human-cell-based confirmation of this module's mitochondrial-dysfunction amplifier step without an animal model. Evidence source is IN_VITRO because the readout comes from a microfluidic human liver organ-chip.

Hepatocyte Cell Death

central effector

Mitochondrial failure and oxidative stress precipitate hepatocyte death by necrosis and apoptosis. This is the central effector step and the most common manifestation of DILI; conforming disorder nodes substitute the drug-specific upstream driver but converge here. It is the key conformance target of the module.

hepatocyte CL:0000182

cell death GO:0008219 ↑ INCREASED apoptotic process GO:0006915 ↑ INCREASED

Used by disorders

Acetaminophen Hepatotoxicity as Centrilobular Oncotic Hepatocyte Necrosis

Isoniazid Toxicity as Hepatocyte Injury and Death

Downstream

Sterile and Immune-Mediated Inflammatory Amplification Hepatocyte death releases damage-associated signals that recruit and activate inflammatory cells.
Liver Injury and Acute Liver Failure Loss of hepatocyte mass produces clinically apparent liver injury.

Show evidence (4 references)

PMID:24099014 SUPPORT Other

"the most common manifestation is hepatocyte death following drug intake"

Directly identifies hepatocyte death as the most common manifestation of DILI, the central effector step of this module. Evidence source is OTHER because this is a review article.

PMID:35024303 SUPPORT Other

"the critical roles of drug metabolism, mitochondrial dysfunction, necrotic cell death, autophagy and the sterile inflammatory response"

Names necrotic cell death (alongside mitochondrial dysfunction and inflammation) as a critical mechanism of hepatotoxicity, supporting the necrosis/apoptosis effector captured here. Evidence source is OTHER because this is a review article.

PMID:39529647 SUPPORT In Vitro

"Unlike traditional models requiring millimolar drug concentrations to detect hepatotoxicity, this platform showed increased sensitivity for acetaminophen and fialuridine at micromolar concentrations."

New Approach Methodology (NAM) evidence: iPSC-derived human liver organoids maintained on a microfluidic chip reproduce hepatocyte injury from the archetypal reactive-metabolite hepatotoxicant acetaminophen (and from fialuridine) at clinically relevant micromolar exposures, giving human-cell-based support for this module's central hepatocyte-death effector step. Evidence source is IN_VITRO because the finding comes from an iPSC-derived liver organoid chip culture.

+ 1 more reference

Sterile and Immune-Mediated Inflammatory Amplification

amplifier

Dying hepatocytes release damage-associated molecular patterns that drive a sterile inflammatory response; in idiosyncratic DILI, innate and adaptive immune activation (death-ligand signaling, HLA-restricted responses) further propagates injury. Inflammation amplifies and extends the hepatocellular death initiated upstream.

hepatocyte CL:0000182 Kupffer cell CL:0000091 neutrophil CL:0000775 CD8-positive cytotoxic T cell CL:0000794

inflammatory response GO:0006954 ↑ INCREASED T cell mediated immunity GO:0002456 ↑ INCREASED

Used by disorders

Isoniazid Toxicity as Immune-Mediated Amplification of Hepatic Injury

Downstream

Liver Injury and Acute Liver Failure Sustained inflammatory injury extends hepatocyte loss toward clinical liver failure.

Show evidence (4 references)

PMID:24099014 SUPPORT Other

"The fundamental process in DILI is the death of hepatocytes (in some circumstances, cholangiocytes or endothelial cells) in the background or recruitment of inflammation."

States that hepatocyte death in DILI occurs against a background of, or with recruitment of, inflammation — the amplification step of this module. Evidence source is OTHER because this is a review article.

PMID:24099014 SUPPORT Other

"how a drug or its metabolites initiate and propagate cell death within the liver with the assistance of surrounding immune cells"

Frames immune cells as propagators of drug-induced hepatocyte death, supporting the inflammatory amplification node. Evidence source is OTHER because this is a review article.

PMID:41001778 SUPPORT In Vitro

"The system captures hallmark features of adaptive immune-mediated hepatotoxicity, including secretion of tumor necrosis factor-alpha and Granzyme B, and cytokeratin-18 release from injured hepatocytes."

New Approach Methodology (NAM) evidence: an HLA-genotyped human liver organoid co-cultured with autologous CD8-positive T cells reconstitutes the adaptive, HLA-restricted arm of this amplifier node in a purely human system — cytotoxic mediator secretion (TNF-alpha, granzyme B) with cytokeratin-18 release marking hepatocyte injury. Evidence source is IN_VITRO because the finding comes from an iPSC-derived organoid-T cell co-culture.

+ 1 more reference

Liver Injury and Acute Liver Failure

consequence

Accumulated hepatocyte loss and inflammation produce clinically apparent liver injury, manifesting as a hepatocellular, cholestatic, or mixed biochemical pattern, and in severe cases progressing to acute liver failure — the most feared consequence of DILI and a leading cause of drug attrition.

hepatocyte CL:0000182

cell death GO:0008219 ↑ INCREASED

Used by disorders

Acetaminophen Hepatotoxicity as Acetaminophen-Induced Acute Liver Injury and Failure

Isoniazid Toxicity as Isoniazid-Induced Liver Injury

Show evidence (3 references)

PMID:24099014 SUPPORT Other

"DILI manifests clinically with hepatocellular injury, cholestasis or a mixture of both."

Defines the clinical injury patterns (hepatocellular, cholestatic, mixed) that constitute the consequence of this module. Evidence source is OTHER because this is a review article.

PMID:24099014 SUPPORT Other

"Acetaminophen (APAP) alone accounts for the half of the overall cases of acute liver failure in USA"

Documents progression to acute liver failure (acetaminophen being the leading cause in the USA), the severe endpoint of this module. Evidence source is OTHER because this is a review article.

PMID:32511920 SUPPORT Other

"drug-induced liver injury (DILI) is a leading cause of preclinical and clinical drug terminations"

Establishes the clinical and translational significance of DILI as a leading cause of drug terminations. Evidence source is OTHER because this is a review article.