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Mechanisms of hepatotoxicity associated with the monocyclic β-lactam antibiotic BAL30072

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BAL30072 is a new monocyclic β-lactam antibiotic under development which provides a therapeutic option for the treatment of severe infections caused by multi-drug-resistant Gram-negative bacteria. Despite the absence of liver toxicity in preclinical studies in rats and marmosets and in single dose clinical studies in humans, increased transaminase activities were observed in healthy subjects in multiple-dose clinical studies. We, therefore, initiated a comprehensive program to find out the mechanisms leading to hepatocellular injury using HepG2 cells (human hepatocellular carcinoma cell line), HepaRG cells (inducible hepatocytes derived from a human hepatic progenitor cell line), and human liver microtissue preparations. Our investigations demonstrated a concentration- and time-dependent reduction of the ATP content of BAL30072-treated HepG2 cells and liver microtissues. BAL30072 impaired oxygen consumption by HepG2 cells at clinically relevant concentrations, inhibited complexes II and III of the mitochondrial electron transport chain, increased the production of reactive oxygen species (ROS), and reduced the mitochondrial membrane potential. Furthermore, BAL 30072 impaired mitochondrial fatty acid metabolism, inhibited glycolysis, and was associated with hepatocyte apoptosis. Co-administration of N-acetyl-l-cysteine partially protected hepatocytes from BAL30072-mediated toxicity, underscoring the role of oxidative damage in the observed hepatocellular toxicity. In conclusion, BAL30072 is toxic for liver mitochondria and inhibits glycolysis at clinically relevant concentrations. Impaired hepatic mitochondrial function and inhibition of glycolysis can explain liver injury observed in human subjects receiving long-term treatment with this compound.

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Alanine aminotransferase


Aspartate aminotransferase


Buthionine sulphoximine


Cytochrome P450


Drug-induced liver injury




Dulbecco’s phosphate buffered saline


Extracellular acidification rate


Carbonyl cyanide-4-(trifluoromethoxy)phenylhydrazone


Food and drug administration (US)


Glyceraldehyde 3-phosphate dehydrogenase


Reduced glutathione

H and E:

Hematoxylin and Eosin


4-(2-Hydroxyethyl)piperazine-1-ethanesulfonic acid


High-mobility group protein B1


Lactate dehydrogenase






Oxygen consumption rate


Phosphate-buffered saline


Reactive oxygen species


Upper limit of normal


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Scott Eaddy (UNC Institute for Drug Safety Sciences) provided laboratory assistance for quantification of miRNA122 and Total HMGB1 in clinical samples. The authors acknowledge the provision of medical writing services by David Main, Basilea Pharmaceutica International Ltd.

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Correspondence to Stephan Krähenbühl.

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Conflict of interest

SK was a member of the Data and Safety Monitoring Board (DSMB) for the phase 1 studies of BAL30072. FP has acted as a consultant for Basilea Pharmaceutica International Ltd.

Financial support

SK was supported by a grant of the Swiss National Science Foundation (31003A_156270).

The studies investigating the potential of BAL30072 to form reactive metabolites that conjugate covalently to proteins were funded with Federal funds from the Department of Health and Human Services; Office of the Assistant Secretary for Preparedness and Response; Biomedical Advanced Research and Development Authority, under Contract No. HHSO100201300010C.

Ethical conduct of clinical studies

The clinical studies of BAL30072 referred to in this manuscript were conducted in accordance with the International Conference on Harmonisation Guideline for Good Clinical Practice E6, with ethical principles consistent with those laid down in the Declaration of Helsinki, and with applicable local laws and regulations.

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Paech, F., Messner, S., Spickermann, J. et al. Mechanisms of hepatotoxicity associated with the monocyclic β-lactam antibiotic BAL30072. Arch Toxicol 91, 3647–3662 (2017).

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