Acetaminophen (N-acetyl-p-aminophenol [APAP]) is one of the leading causes of acute liver failure, and APAP hepatotoxicity is associated with coagulopathy in humans. We tested the hypothesis that activation of the coagulation system and downstream protease-activated receptor (PAR)-1 signaling contribute to APAP-induced liver injury. Fasted C57BL/J6 mice were treated with either saline or APAP (400 mg/kg intraperitoneally) and were euthanized 0.5-24 hours later. Hepatotoxicity and coagulation system activation occurred by 2 hours after administration of APAP. Treatment with APAP also caused a rapid and transient increase in liver procoagulant activity. In addition, significant deposition of fibrin was observed in the liver by 2 hours, and the concentration of plasminogen activator inhibitor-1 in plasma increased between 2 and 6 hours. Pretreatment with heparin attenuated the APAP-induced activation of the coagulation system and hepatocellular injury and diminished hepatic fibrin deposition at 6 hours. Loss of hepatocellular glutathione was similar in APAP-treated mice pretreated with saline or heparin, suggesting that heparin did not diminish bioactivation of APAP. In mice deficient in tissue factor, the principal cellular activator of coagulation, APAP-induced liver injury, activation of coagulation, and hepatic fibrin deposition were reduced at 6 hours. A cetaminophen (N-acetyl-p-aminophenol [APAP]) is the leading cause of drug-induced hepatic failure in humans. Early results in animal models revealed that APAP is bioactivated to a reactive metabolite that is responsible for the hepatotoxicity. 1,2 Many subsequent studies have identified numerous factors that appear to contribute to APAP-induced liver injury, including mitochondrial alterations, reactive oxygen and nitrogen species, and cytokines such as tumor necrosis factor-␣. [3][4][5][6][7][8] Despite extensive study, the factors and mechanisms involved in the initiation and progression of hepatocellular lesions during APAP hepatotoxicity are not fully understood.Disturbances in the hemostatic system are well documented in human patients with APAP hepatotoxicity. During hemostasis, formation and lysis of clots is regulated by the balance among coagulant, anticoagulant and fibrinolytic pathways. 9 The coagulation system is activated by tissue factor (TF), and this culminates in the generation of thrombin and formation of insoluble fibrin clots. Dissolution of fibrin clots is mediated by plasmin and is inhibited by plasminogen activator inhibitor-1 (PAI-1). In people who develop APAP-induced liver injury, prothrombin time increases, and this change correlates with the severity of toxicity. [10][11][12] Moreover, the concentrations of several coagulation factors are decreased in APAP-poisoned patients, 13 an effect that could be interpreted to be a consequence of decreased production of coagulation factors by the injured liver. An alternative interpretation, however, is that the decrease in coagula-