Journal of Immunoassay and Immunochemistry

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Hepatoprotective effect of artichoke leaf extracts

in comparison with silymarin on acetaminophen-
induced hepatotoxicity in mice

Ghada Elsayed Elgarawany, Asmaa Gaber Abdou, Doha Maher Taie &
Shaimaa Mohammed Motawea

To cite this article: Ghada Elsayed Elgarawany, Asmaa Gaber Abdou, Doha Maher Taie
& Shaimaa Mohammed Motawea (2019): Hepatoprotective effect of artichoke leaf extracts
in comparison with silymarin on acetaminophen-induced hepatotoxicity in mice, Journal of
Immunoassay and Immunochemistry, DOI: 10.1080/15321819.2019.1692029

To link to this article: https://doi.org/10.1080/15321819.2019.1692029

Published online: 18 Nov 2019.

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JOURNAL OF IMMUNOASSAY AND IMMUNOCHEMISTRY
https://doi.org/10.1080/15321819.2019.1692029

Hepatoprotective effect of artichoke leaf extracts in

comparison with silymarin on acetaminophen-induced
hepatotoxicity in mice
Ghada Elsayed Elgarawany a, Asmaa Gaber Abdoub, Doha Maher Taiec,
and Shaimaa Mohammed Motaweaa
a
Medical Physiology Departments, Faculty of Medicine, Menoufia University, Shebein El-
Kom, Egypt; bPathology Department, Menoufia University, Shebein El-Kom, Egypt; cFaculty of
Medicine, Pathalogy Department, National Liver Institute, Menoufia University, Shebein El-Kom, Egypt

ABSTRACT KEYWORDS
Acetaminophen is a common analgesic-antipyretic agent, Artichoke; silymarin;
which is safe in therapeutic doses but in higher doses can acetaminophen;
produce hepatic necrosis. The aim of this study is to hepatotoxicity; PCNA;
investigate the hepatoprotective effects of artichoke, sily- immunohistochemistry
marin, and both agents in acetaminophen-induced liver
damage in mice. Forty male mice were divided into five
main groups, (1) control (2) Acetaminophen (APAP) (3)
Artichoke leaf extracts (ALE) and APAP (4) silymarin and
APAP group (5) ALE, silymarin and APAP groups. Blood
samples were collected for the measurement of liver
enzymes (ALT, AST, and ALP). The liver was excised,
weighed and dissected into two parts, one used for mea-
surement of malondialdehyde (MDA) and glutathione
reductase, and the other part used for histopathological
examination and assessment of proliferative cell nuclear
antigen (PCNA) immunohistochemical expression. APAP
group showed a significant increase in liver weight, ALT,
AST, ALP, MDA, and PCNA expression with a significant
decrease in glutathione reductase in comparison to control
group. All these parameters were significantly improved in
the three treated groups when compared to APAP
group. APAP group showed marked portal inflammation
and parenchyma necrosis. Co-administration of ALE and/
or silymarin to acetaminophen treated mice showed
a significant reduction in PCNA expression compared to
APAP group. Both ALE and silymarin co-treatment showed
a significant decrease in PCNA percentage to a level near
to control group. Artichoke and/or silymarin are suggested
to protect against acetaminophen-induced hepatotoxicity
in mice by ameliorating liver enzymes, antioxidant effect,
decreasing liver damage and proliferation.
Abbreviation: ALT, alanine transaminase. AST, aspartate trans-
aminase. ALP, alkaline phosphatase.MDA, malondialdehyde.
PCNA, proliferative cell nuclear antigen

CONTACT Asmaa Gaber Abdou asmaa_elsaidy@yahoo.com, Menoufia, Egypt

Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ljii.
© 2019 Taylor & Francis
2 G. ELSAYED ELGARAWANY ET AL.

Introduction
The liver is a crucial organ, which plays an important role in maintaining
homeostasis, physiological, biochemical activity, growth, and nutrition.[1] It is
one of the important organs in the metabolism and detoxification of drugs and
chemicals. Many toxic drugs can cause liver damage such as acetaminophen,
chloroform, galactosamine, and dimethylnitrosamine.[2] Acetaminophen (para-
cetamol) is one of the most pharmaceutical drugs poisoning in the USA.[3] It is
used as an analgesic and an antipyretic drug. It is safe at a therapeutic dose, but
in overdose, it causes hepatic necrosis and acute liver damage.[4]
Artichoke (Cynarascolymos) is a plant that has been used as a food in
traditional medicine. It contains many minerals like iron and calcium, vitamins
like A, B, and C and bioactive agents as luteolin and cynarine.[5] Cynarine is the
biologically active chemical constituent of artichoke and is located in the pulp
of the leaves.[6] It was used as anti-inflammatory, anti-allergic and anticancer
and for treatment of hyperlipidemia.[7] Silymarin is used for the treatment of
chronic liver disease and pretreatment with silymarin prevents hepatic injury
and liver fibrosis caused by toxins (i.e., ethanol, and CCl4).[8]
The hepatoprotective effect of artichoke is not widely studied[9,10], there-
fore the present study investigates this effect of artichoke leaf extract in
comparison with silymarin in acetaminophen-induced hepatotoxicity of
male albino rats and their possible underlying mechanisms.

Material and methods

This study was performed according to the guide for the care and use of
laboratory animals published by the US National Institutes of Health and the
present protocol was approved by the local ethics committee of Faculty of
Medicine, Menoufia University.

Experimental design
Forty male albino mice of C57BL/6 weighing30 ± 10 g were fed with standard
laboratory diet and water “adlibitum” and housed in the animal house at the
Faculty of Medicine, Menoufia University, under normal light/dark cycle and
room temperature. The animals were acclimatized to these conditions for 7 days
before the experiment. The animals were classified into five groups, eight animals
for each one.
Group 1: Control group
Group 2: Acetaminophen (APAP) group: Acetaminophen was given in
a dose of 300 mg/kg intraperitoneally (I.P) as a single dose.[11]
Group 3: Artichoke leaf extracts (ALE) and APAP(ALE+APAP) group:
Artichoke leaf extract was dissolved in distilled water and given in a dose of
 JOURNAL OF IMMUNOASSAY AND IMMUNOCHEMISTRY 3

300mg/kg for 14 days by oral gastric tube[12,13] followed by acetaminophen

(300 mg/kg I.P) as a single dose, 1 h after the last dose of ALE.
Group 4: Silymarin and APAP (Silymarin+APAP) group: Silymarin was
used as a standard drug, which was dissolved in distilled water and given in
a dose of 200mg/kg by oral gastric tube[14] for 14 days followed by acetami-
nophen (300 mg/kg I.P) as a single dose, 1 h after the last dose of silymarin.
Group 5: ALE, silymarin and APAP (ALE+silymarin+APAP) group:
Artichoke leaf extracts and silymarin were given in a dose of 300mg/kg and
200mg/kg, respectively by oral gastric tube for 2 weeks followed by acetaminophen
(300 mg/kg I.P) as a single dose, 1 h after the last dose of ALE and silymarin.

Artichoke leaves extract preparation

Artichoke leaves were cut into smaller pieces and left to dry under shade in order to
obtain a powder. Dried leaves were grounded and extracted with ethanol: water
(70:30) v/v for 2 days at room temperature. This extract was filtered using filter
paper (Whatman No 1), and evaporated below reduced pressure using Rotovapor
at 40°C. After the total evaporation of the hydroethanolic solvent, greenish-brown
residues were obtained and stored at 5°C until usage.[15]
At the end of the experiment after 24 h of APAP administration, retro-
orbital blood samples were collected. About 1 ml of blood were collected
in a sterile serum container and kept undisturbed at 37° for 45 min. The
serum was aspirated using a sterile pipette after centrifugation at
3000 rpm for 15 min.[11,16] for estimation of liver enzymes. Mice were
then sacrificed by cervical decapitation, the liver was excised and weighed
and then dissected into two parts, one for histopathological study and the
other part was used for measurement of malondialdehyde (MDA) and
glutathione reductase.

Measurement of liver enzymes

Blood samples were used to measure liver enzymes (ALT, AST, and ALP)
using the kinetic method as previously described.[17] Liver enzymes commer-
cial kits were purchased from BioMed, Diagnostic, EgyChem, Egypt.

Measurement of MDA and glutathione reductase

Liver tissue was washed using saline then put in homogenized phosphate buffer
(K2HPO4 and KH2PO4). The homogenized tissues were then centrifuged using
a cold centrifuge at 1000 × g for 10 min at 4 °C. The supernatant was collected
and frozen at −20°C. MDA was measured using the thiobarbituric reaction.[18]
4 G. ELSAYED ELGARAWANY ET AL.

Glutathione reductase was measured by the calorimetric method.[19] MDA and

glutathione reductase were purchased from Biodiagnostic Company, Giza,
Egypt.

Histopathological assessment of liver specimens

The liver tissue samples from each group were fixed in 10% formalin for 24 h,
routinely processed, embedded in paraffin, sectioned and stained with hema-
toxylin and eosin. The degree of necro-inflammatory activity was assessed.

Proliferative cell nuclear antigen (PCNA) immunohistochemical study

The method used for immunostaining was a streptavidin-biotin–amplified
system. Paraffin-embedded tissue sections were deparaffinized in xylene,
rehydrated in a graded series of ethanol, and then incubated with 3%
hydrogen peroxide. Slides were rinsed in phosphate-buffered saline and
then exposed to heat-induced epitope retrieval in citrate buffer solution
(pH 6) for 20 min. After cooling, the slides were incubated overnight at
room temperature with ready-to-use mouse monoclonal antibody raised
against proliferative cell nuclear antigen (PCNA)(Clone PC10, Thermo
Fisher Scientific, UK). Detection of immunoreactivity was carried out using
the ultravision detection system, ready-to-use antipolyvalent horseradish
peroxidase/diaminobenzidine (NeoMarkers, Lab Vision). Finally, the reac-
tion was visualized by an appropriate substrate/chromogen (diaminobenzi-
dine) reagent. Mayer’s hematoxylin was used as a counterstain. The staining
procedure included negative controls obtained by substitution of primary
antibodies with phosphate-buffered saline. Positive control for PCNA was
slides prepared from breast carcinoma. Nuclear expression in any number of
cells was required to assign positivity for PCNA. The percentage of positivity
was expressed as mean ± standard error.

Reagents
Silymarin: Legalon capsule (140 mg) (Chemical Industrial Development,
Giza, Egypt). Acetaminophen: Perfalgan (Paracetamol) solution 10mg/ml
(Bristol-Myers Squibb, LOC,
Fontana del Ceraso, Anagani, Italy).

Statistics
Values were measured as the mean ± standard error of the mean (S.E.M).
Analysis of variance (ANOVA) followed by post hoc (Tukey’s) test using
SPSS version 16. P < .05 was significant.
 JOURNAL OF IMMUNOASSAY AND IMMUNOCHEMISTRY 5

Results
Liver weight (g)
Liver weight increased in acetaminophen treated group (1.63 ± 0.028) when
compared to control group (p < .0001). Co-administration of ALE or silymarin
or both to acetaminophen treated group significantly showed a decrease in liver
weight (1.46 ± 0.024, 1.32 ± 0.057, and 1.2 ± 0.029, p < .05, p < .0001 and p <
.0001, respectively) compared to APAP group (Figure 1a).

Liver enzymes (ALT, AST, and ALP) (table 1)

ALT: APAP group showed a significant increase in ALT level (334.2 ± 20.18,
p < .0001) in comparison to other groups. (ALE + APAP), (Silymarin+
APAP), and (ALE +Silymarin +APAP) groups showed a significant decrease
in ALT level (128 ± 19.78, 66.9 ± 21.77 and 40.86 ± 20.56, respectively, p <
.0001) compared to APAP group. (ALE + APAP) group showed a significant
increase in ALT level (p < .05) compared to (ALE+ silymarin +APAP) group.
AST: APAP group showed a significant increase in AST level (467.8 ±
20.18, p < .0001) compared to other groups. (ALE + APAP), (silymarin +
APAP), and (ALE +Silymarin+APAP) groups showed a significant decrease
in AST level (135.7 ± 17.23, 96.5 ± 30.4 and 76.3 ± 16.36, respectively, p <
.001) compared to APAP group.

Figure 1. (A): The changes in liver weight/g among the different studied groups [control, APAP,
(ALE + APAP), (Silymarin+APAP), and (ALE+ Silymarin +APAP)]. (B): The difference in the level of
MDA (nmol/gm) among the studied groups [control, APAP, (ALE + APAP), (Silymarin+APAP), and
(ALE+ Silymarin +APAP)]. (C): Glutathione reductase (mg/gram tissue) in control, APAP, (ALE +
APAP), (Silymarin + APAP), and (ALE+ Silymarin + APAP) groups.
6 G. ELSAYED ELGARAWANY ET AL.

Table 1. ALT, AST, and ALP (U/L) in control, APAP, (ALE + APAP), (Silymarin + APAP), and (ALE+
Silymarin +APAP) groups.
Groups
Liver
enzymes Control APAP ALE+APAP Silymarin+APAP ALE+Silymarin+APAP
ALT(U/l) 75.82 ± 17.78 334.2 ± 20.18* 128.8 ± 19.78#& 66.9 ± 21.77# 40.86 ± 20.56#
AST(U/l) 132.7 ± 30.3 467.8 ± 31.3* 135.7 ± 17.23# 96.5 ± 30.4# 76.3 ± 16.36#
ALP(U/l) 52.5 ± 5.43 321.9 ± 40.38* 140.5 ± 6.44*# 150.6 ± 4.1*# 61.7 ± 6.9$%#
Values are measured as mean ± S.E.M. *Significant when compared to the control group.# Significant when
compared to APAP group.$ Significant when compared to ALE + APAP group.%Significant when compared
to Silymarin + APAP group.&Significant when compared to (ALE+ Silymarin+ APAP) group.

ALP: ALP level was significantly increased in APAP group (321.9 ± 5.43,
p < .0001) in comparison to other groups. (ALE +APAP) and (Silymarin+
APAP) showed a significant decrease in ALP level (140.5 ± 6.44 and 150.6 ±
4.1, p < .0001, respectively) compared to APAP group while they showed
significant increase in ALP level (p < .05, p < .01, respectively) when
compared to control and (ALE+ silymarin +APAP) groups.

MDA (nmol/gm)
APAP group showed a significant increase in MDA level (38.49 ± 2.9, p < .0001)
compared to other groups. Co-administration of ALE to APAP and silymarin to
APAP and both ALE and silymarin to APAP significantly showed a decrease in
MDA (15.5 ± 2.66, 16.4 ± 2.63 and 14.9 ± 1.64, respectively) compared to APAP
group. No significant differences were detected among (ALE + APAP),
(Silymarin+ APAP) and (ALE+ silymarin +APAP) groups (Figure 1b).

Glutathione reductase (mg/gram tissue)

APAP group showed a significant decrease in glutathione reductase (3.39 ±
0.43) in comparison to other groups. Co-administration of ALE to APAP and
silymarin to APAP and both ALE and silymarin to APAP showed
a significant increase in glutathione reductase (7.6 ± 0.65,p < .01, 10.1 ±
0.39,p < .0001& 7.78 ± 0.32,p < .01, respectively) compared to APAP group.
However, no significant differences were detected among (ALE+APAP),
(silymarin+ APAP), and (ALE+Silymarin+APAP) groups (Figure 1c).

Histopathology
Normal control rat’s liver showed preserved lobular architecture. Regarding
necro-inflammatory activity, APAP group showed marked portal inflamma-
tion and parenchymal necrosis compared to other groups where there was
a recognized decrease in the degree of necro-inflammatory activity (Figure 2)
 JOURNAL OF IMMUNOASSAY AND IMMUNOCHEMISTRY 7

Figure 2. a, Normal control mouse liver showing classic hepatic lobule (H&E, x 200). b&c,
Acetaminophen treated mice livers showing b, portal tract inflammation (red arrow). c, perivenular
necrosis and ballooning swelling of hepatocytes (yellow arrows) together with multiple foci of spotty
necrosis (green arrows) (H&E, x 200). d, ALE and APAP treated group, where liver showing minimal portal
inflammation (red arrow) (H&E, x 200). e, Silymarin and APAP treated group, liver showing focal spotty
necrosis (red arrow) (H&E, x 200). f, ALE, Silymarin and APAP treated group, liver showing minimal
parenchyma inflammation(H&E, x 200).

Results of immunohistochemical of PCNA expression

In control group, there were few numbers of positive cells indicating low cell
proliferation. After the administration of acetaminophen to mice, liver hepato-
cyte showed high numbers of positive PCNA cells (high percentage of PCNA
expression) (25.8 ± 1.1%, p < .0001) compared to control group. Co-
administration of ALE alone and silymarin alone to acetaminophen treated
mice showed a significant decrease in PCNA expression (14.5 ± 0.75% and 7.2
± 0.52%, respectively, p < .0001) compared to APAP group. Both ALE and
silymarin co-treatment to acetaminophen treated mice showed a significant
decrease in PCNA percentage of expression (4.9 ± 0.37%, p < .0001) compared
to APAP group approaching values of the control group (Figure 3 and Table 2).

Discussion
Acetaminophen overdose caused severe hepatotoxicity, acute liver damage, and
death.[20,21] In our study, we investigated the role of artichoke and silymarin as
8 G. ELSAYED ELGARAWANY ET AL.

Figure 3. a: Control group showed hepatocyte with few nuclear positive cells for PCNA (2%). b:
APAP group showed increased nuclear positivity (black arrow) and strongly stained PCNA
expression (25%) c:ALE +APAP group showed decrease nuclear positivity of PCNA expression
(15%).d: Silymarin +APAP group showed decrease nuclear positivity of PCNA expression (7%). e:
ALE+silymarin +APAP group showed a few positive cells for PCNA (5%).(IHC x 200).

Table 2. PCNA expression (%) in control, APAP, (ALE + APAP), (Silymarin + APAP), and (ALE+
Silymarin +APAP) groups.
Control APAP ALE+APAP Silymarin+APAP ALE+Silymarin+APAP
PCNA (%) 2.1 ± 0.18 25.8 ± 1.1* 14.5 ± 0.75*#%& 7.2 ± 0.52*# 4.9 ± 0.37*#
The number of rats in each group was 8. Values are measured as mean ± S.E.M. *Significant when compared
to the control group. # Significant when compared to APAP group.$ Significant when compared to ALE +
APAP group.% Significant when compared to Silymarin + APAP group.&Significant when compared to
(ALE+ Silymarin+ APAP) group.

hepatoprotective drugs against acute acetaminophen intoxication. Our study

showed a significant increase in liver weight and liver enzymes (ALT, AST, and
ALP) after acetaminophen treatment. Co-treatment by artichoke alone or by
silymarin alone or by both in rats receiving acetaminophen showed significant
decrease in liver weight and liver enzymes when compared to acetaminophen
non-treated group. Acetaminophen overdose induced liver toxicity and hydro-
pic degeneration and spotty necrosis so, it was expected to cause an increase in
liver weight. This result was in agreement with Mahmood et al.[1]who reported
 JOURNAL OF IMMUNOASSAY AND IMMUNOCHEMISTRY 9

that the enlargement of livers in paracetamol-treated rats may be due to the

accumulation of extracellular matrix protein and collagen in liver tissue.[1]
ALT, AST, and ALP are intracellular enzymes and were suggested to be
increased in the blood due to acute liver damage and liver necrosis after
acetaminophen overdose.[1,21]
Artichoke leaves extract contains a complex of chemical components. The
most important substances are caffeoylquinic acid derivatives such as 1,3-di-
O-caffeoylquinic acid (cynarin), 5-O-caffeoylquinicacid (chlorogenic acid),
and 1,5-di-O-caffeoylquinic acid), flavonoids, and sesquiterpene bitter
agents. The Hepatoprotective effect of artichoke extract depends on caffeoyl-
quinic acids contents.[22] Some studies identified bioactive components as
luteolin, caffeic acid, cynarin, and cholinergic acid, which decrease the
production of lipid peroxidation, reactive oxygen species, and low-density
lipoproteins in vitro experiments[15,23]
Artichoke leaf extract treatment decreased liver weight and liver enzymes
since it decreased liver damage and normalized the histological pattern after
acetaminophen intoxication and hence it decreased liver enzymes released
from hepatocyte beside its role as an antioxidant. It has been reported that
artichoke leaf extract decreased ALT, AST, and ALP to that of normal control
after the intoxication of rats with lead.[15] Silymarin was used as a standard
drug in our study, as silymarin was reported to protect against hepatotoxic
agents (acetaminophen, excess iron, ethanol and carbon tetrachloride).[24,25]
Decrease liver damage was expected with silymarin use, which explained
decrease in liver enzymes and weight.
Combined artichoke leaf extract and silymarin showed a highly significant
reduction (p < .0001) in liver enzymes and weight when compared to
acetaminophen treated group with the result near to the control group.
Combinations between the two drugs potentiate the hepatoprotective effect
as they decreased liver damage and normalize the histological architecture of
the liver and decreased reactive oxygen species and increased the antioxidant
effect.
The elevated lipid peroxidation indicated by elevated MDA in liver tissue
homogenate of mice treated with APAP, accompanied by a significant reduc-
tion in glutathione reductase level, indicated oxidative liver damage, which
was confirmed by the histopathological findings of the present study. These
results agreed with others[26,27] who reported that the metabolism of acet-
aminophen triggers lipid peroxidation, which is responsible for liver injury.
Oxidative stress has an important role in the pathophysiological reactions
involving lipid peroxidation. It is well established that at normal doses,
acetaminophen is converted via the cytochrome P-450 pathway to a highly
toxic metabolite, N-acetyl-p-benzoquinoneiminethe reactive metabolite of
APAP in liver cells (NAPQI), which is normally conjugated with glutathione
and excreted in the urine in a conjugated form. Higher doses of
10 G. ELSAYED ELGARAWANY ET AL.

acetaminophen exhaust the glutathione stores, leading to the accumulation of

NAPQI, mitochondrial dysfunction and the development of acute hepatic
necrosis.[28]
Our result revealed a significant reduction in glutathione reductase level in
liver tissue homogenate of mice treated with APAP, which coincided with the
results of Rasool et al.[29] who concluded that acetaminophen significantly
increases the levels of lipid peroxidation and causes the depletion of anti-
oxidants (superoxide dismutase, catalase, glutathione peroxidase, glutathione
reductase, glutathione-S-transferase, and glutathione).
Pretreatment with artichoke leaf extract significantly suppressed the eleva-
tion of MDA caused by APAP with significant elevation of the glutathione
reductase level. This antioxidant effect may be due to the presence of
biologically active substances as flavonoids and cynarin, which agreed with
different studies about health-protective potential, especially hepatoprotective
role of artichoke[30,31] and anti-inflammatory activities.[32] The hepatopro-
tective activity of ALE against CCl4 toxicity in isolated rat hepatocytes was
due to some polyphenolic compounds, such as cynarin, isochlorogenic acid,
chlorogenic acid, luteolin-7-O-glucoside, and two organic acids (caffeic and
quinic) from C.scolymus.[33]
Also, pretreatment with silymarin significantly suppressed the elevation of
MDA with significant elevation of the glutathione reductase level, these
results were in agreement with Freitag et al.,.[34] The latter authors revealed
that pretreatment with silymarin decreased NO production and neutrophil
infiltration in the hepatic tissue, suggesting the anti-inflammatory and anti-
free radical properties of this drug in reducing the severity of hepatic damage
when compared to that observed after APAP treatment.
Regarding ALE, silymarin and APAP group, there were also improvements
in oxidative stress parameters with no statistically significant difference
between the three treated groups. This may be due to the similarities in the
mechanisms of protection as anti-inflammatory and antioxidant agents.
Expression of proliferating cell nuclear antigen (PCNA) was significantly
higher in APAP group when compared to the normal control group, most
probably to restore homeostasis, this is supported by Shen and Pervaiz[35]
who indicated that Kupffer cell activation led to increases in both pro-
inflammatory and anti-inflammatory cytokines. Cytokines have important
functions in immunity, inflammation, cell proliferation, differentiation, and
cell death.[35] Artichoke leaf extract treatment and silymarin treatment sig-
nificantly decreased PCNA percentage of expression; this is most probably
due to decreased inflammatory infiltrate encountered in the studied speci-
mens resulting in a decrease in cytokine levels with subsequent suppression
of proliferation and decreased oxidative stress. In group 5, using artichoke
leaf extract and silymarin together as a prophylactic agent significantly
decreased PCNA expression compared to artichoke leaf extract alone,
 JOURNAL OF IMMUNOASSAY AND IMMUNOCHEMISTRY 11

which may be due to the additive effect of silymarin in elevation of glu-

tathione reductase agreeing with Kavitha et al.[36] GSH has been reported to
play an important role in the detoxification of acetaminophen and protection
of the liver cells by uniting with reactive metabolites of paracetamol. Thus, it
inhibits them from binding covalently with the proteins of the liver. The
reduction of GSH exposes the cell to the destructive effects of oxidative
stress.[36]

ORCID
Ghada Elsayed Elgarawany http://orcid.org/0000-0002-5435-4205

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