Drug induced liver injury (DILI) is a serious and potentially life-threatening condition resulting from an adverse drug reaction. Both the clinical manifestations and pathological mechanisms of DILI vary depending on drug characteristics, dose, duration of exposure as well as host specific factors. Disease onset can occur within days or months after the introduction of a drug. This has challenged identification of disease specific biomarkers and resulted in delayed and even erroneous diagnosis of patients. Apart from discontinuation of current pharmacotherapy, options for DILI patients are scarce and the condition can sometimes continue or worsen after drugs are discontinued or result in irreversible liver damage such as cirrhosis. This illustrates the need to uncover relevant pathological pathways that will pave the road for targeted interventions. In an effort to accommodate these needs, novel insights from preclinical and cellular disease modeling have allowed coupling of specific drugs to potential mechanisms of toxicity. This review outlines three signaling pathways of DILI: organelle stress, cholestasis, and immune responses, discusses their interplay with oxidative stress, and provides examples of drugs specifically targeting one or more steps in these pathways. A systematic approach identifying specific mechanisms of DILI could allow for the assembly of large databases, in turn enabling advanced computational modelling to provide accurate predictions of the DILI potential of both known drugs and future drug candidates. pmc Cell Mol Life Sci Cell Mol Life Sci 4579 cmls Cellular and Molecular Life Sciences: CMLS 1420-682X 1420-9071 Springer PMC12106265 PMC12106265.1 12106265 12106265 40418327 10.1007/s00018-025-05744-3 5744 1 Review Mechanisms of drug induced liver injury http://orcid.org/0000-0002-8160-9330 Skat-Rørdam J. 1 Keywords Drug induced liver injury Hepatotoxicity Organelle stress Cholestasis Herbal and dietary supplements http://dx.doi.org/10.13039/501100009708 Novo Nordisk Fonden NNF20SA0064340 Skat-Rørdam J. pmc-status-qastatus 0 pmc-status-live yes pmc-status-embargo no pmc-status-released yes pmc-prop-open-access yes pmc-prop-olf no pmc-prop-manuscript no pmc-prop-legally-suppressed no pmc-prop-has-pdf yes pmc-prop-has-supplement no pmc-prop-pdf-only no pmc-prop-suppress-copyright no pmc-prop-is-real-version no pmc-prop-is-scanned-article no pmc-prop-preprint no pmc-prop-in-epmc yes pmc-license-ref CC BY-NC-ND issue-copyright-statement © Springer Nature Switzerland AG 2025 Introduction Drug induced liver injury (DILI) is an iatrogenic and potentially life-threatening liver damage, posing a risk of detrimental consequences for patient health and survival. Depending on the drug, hepatocellular stress can be induced by various mechanisms that are clinically reflected by the variety of biochemical and histological phenotypes observed among DILI patients. The R value is used to classify the pattern of liver injury and is calculated using liver enzymes. Generally, the R value can help evaluate if the injury is primarily hepatocellular (ALT ≥ 5 times the upper limit of normal or an R value ≥ 5 (defined as [ALT ÷ the upper limit of normal ALT] ÷ [ALP ÷ the upper limit of normal ALP])), cholestatic (ALP ≥ 2 upper limit of normal or R value of ≤ 2) or mixed pattern of injury (R value of > 2 to < 5). In a mechanism involving mitochondrial stress, reactive oxygen species (ROS) generation and hepatocellular necrosis, the dose vs time relationship directly associated with the degree of liver damage has allowed for targeted studies of isolated effects, defining the causal mechanisms of APAP toxicity. In accordance, hepatocellular pathogenesis is largely known, and APAP-induced DILI is currently the only type of DILI for which there is an evidence based antidote preventing further liver damage [ 30 ]. The term “idiosyncratic DILI” encompasses abnormal or unexpected reactions to a drug or compound by an individual and accounts for 11% of all acute liver failure cases in the U.S [ 3 ]. Accordingly, the mechanisms of DILI covered in this review, will refer to DILI in general unless stated otherwise. Organelle stress in DILI As outlined in Fig. 1 , DILI-induced cell death can be initiated in several ways, depending on the type of drug, dose, duration of drug exposure as well as various host factors [ 41 ]. Within the cellular compartment, the mitochondria and endoplasmatic reticulum (ER) are directly involved in cellular respiration and synthesis and subjected to a high metabolic activity promoting the generation of free radical by-products such as reactive oxygen species. While the majority of mitochondrial proteins are encoded by nuclear DNA, mitochondrial DNA specifically encodes core subunits of complex I, III, IV and the ATP synthase of the electron transport chain [ 67 ]. Thus, mitochondrial DNA damage may indirectly lead to ATP depletion and stress, and several drugs are suggested to induce mitochondrial DNA damage (Table 2 , Fig. 2 ). Studies have shown that this could occur through drug induced ROS generation and subsequent oxidative damage to mitochondrial DNA, which is particularly vulnerable to such insults due to lack of protective histones and its proximity to the origin of ROS generation [ 51 , 67 ]. In APAP overdose patients, both GLDH and mitochondrial DNA were increased, and a more recent study conducted by large international consortia (Critical Path Institute’s predictive safety testing consortium (PSTC), Safer and Faster Evidence Based Translation (SAFE-T), Drug Induced Liver Injury Network (DILIN)), also identified GLDH as a sensitive marker of DILI [ 9 , 148 , 149 ]. Moreover, GLDH and mitochondrial DNA were not increased in mice with furosemide-induced DILI [ 149 ]. Furosemide is a diuretic that can induce liver injury without mitochondrial damage. Thus, this could indicate that GLDH and mitochondrial DNA are specific for DILI with mitochondrial injury.