A lthough nitric oxide (NO) derived from endothelial nitric oxide synthase is always hepatoprotective, inducible NO synthase (iNOS)-derived NO can either protect against or contribute to liver injury. An important determinant in the fate of induced NO is the level of redox stress. In the setting of high redox stress iNOS contributes to damage, 1 whereas in other settings iNOS prevents injury. 2 Ample evidence exists both in vitro and in vivo that NO is a potent inhibitor of apoptosis in hepatocytes. 3 Multiple mechanisms appear to be protective including the direct inhibition of caspases via s-nitrosation, cyclic guanosine monophosphate-dependent interruption of apoptotic signaling, 4 inhibition of proapoptotic proteins, 5 and the up-regulation of protective proteins such as heat shock protein 70 6 and heme oxygenase (HO)-1. 7 In 1995, Kim et al. 8 first showed that NO can increase HO-1 expression in hepatocytes and we recently provided in vivo confirmation that HO-1 up-regulation is iNOS dependent in some settings. 7 The relative importance of the many potential mechanisms for NO is probably situation specific. In this issue of HEPATOLOGY, Choi et al. show pharmacologic NO donor-mediated cytoprotection of hepatocytes from glucose deprivation-induced cytotoxicity to be dependent on HO-1 enzymatic activity. Choi et al. further suggest that the protective effects of HO-1 are secondary to the generation of carbon monoxide (CO), which is one of the catalytic by-products in the breakdown of heme.HO-1 is a 32-kd protein that was identified originally in 1968. It is the inducible isoform in a family of HO enzymes, all of which catalyze the rate-limiting step in the degradation of heme to yield biliverdin, free iron, and CO. Biliverdin is converted subsequently to bilirubin via biliverdin reductase, and free iron is sequestered into ferritin. 9 Initially, HO-1 was thought to be up-regulated as part of a cellular waste management system to deal with increases in heme containing proteins after stress. However, HO-1 is induced not only by heme-containing compounds but also by non-heme-containing substances or environmental conditions including NO, prostaglandins, cytokines, endotoxin, reactive oxygen intermediates, hypoxia, hyperoxia, and heat shock. 9 This vast array of inducers plus an explosion in data showing anti-oxidant, antiinflammatory, and anti-apoptotic properties of HO-1, raises questions of the functional significance and role of this enzyme under physiologic and pathophysiologic circumstances.In the liver (as in other organs) HO-1 is up-regulated by stress and in general is considered to be cytoprotective. 9,10 Physiologically, HO-1 is involved in modulation of hepatic sinusoidal tone and portal venous regulation. 11,12 These effects are thought to be secondary to the generation of CO, activation of guanylyl cyclase, and subsequent production of cyclic guanosine monophosphate, similar to that of NO. The importance of HO-1 in hepatobiliary vascular regulation is emphasized under pathologic conditions of portal ...