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Furthermore, in studies of APAP hepatotoxicity, in which patients have been transferred to a tertiary liver unit, the prognostic ability of elevated plasma acetyl-HMGB1 and KIM-1 (kidney injury) to predict the need for liver transplant, and of elevated CSF-1 to predict spontaneous survival, has been demonstrated.48 Key outcomes from these studies and from collaborations with the IMI funded SAFE-T consortium have resulted in the Letter of Support status for the further qualification of these biomarkers across the spectrum of drug-induced liver injury from the FDA (July 2016)49 and EMA (September 2016).50 By using hepatocyte specific conditional knock-out mice it has also been shown that the inflammatory mediator and biomarker, HMGB1, plays an integral role in the mechanism of toxicity by linking cell death to inflammation.51 In addition, the therapeutic potential of chimeric anti-HMGB1 to block post-injury inflammation and reduce APAP hepatotoxicity, at a time when NAC is ineffective, has recently been demonstrated.52 3

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