This modification is a carboxylation and the enzyme responsible, -glutamyl carboxylase requires vitamin K as a cofactor
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When higher levels of acetaminophen are ingested, the livers supply of glutathione is depleted and NAPQI causes liver damage.[ref] Related article: Genetic variants that increase the risk of liver damage from acetaminophen Studies on the impacts of low glutathione levels: Glutathione levels in the body are fairly tightly regulated, and balance is key