a 1 -Antitrypsin (AAT) deficiency is one of the most common genetic disorders and the liver disease due to the Z mutant of AAT (ATZ) is a prototype of conformational disorder due to protein misfolding with consequent aberrant intermolecular protein aggregation. In the present study, we found that livers of PiZ transgenic mice expressing human ATZ have altered expression of a network of hepatocyte transcriptional factors, including hepatocyte nuclear factor-4a, that is early down-regulated and induces a transcriptional repression of ATZ expression. Reduced hepatocyte nuclear factor-4a was associated with activation of b-catenin, which regulates liver zonation. Livers of PiZ mice and human patients with AAT deficiency were both found to have a severe perturbation of liver zonation. Functionally, PiZ mice showed a severe defect of ureagenesis, as shown by increased baseline ammonia, and reduced urea production and survival after an ammonia challenge. Down-regulation of hepatocyte nuclear factor-4a expression and defective zonation in livers have not been recognized so far as features of the liver disease caused by ATZ and are likely involved in metabolic disturbances and in the increased risk of hepatocellular carcinoma in patients with AAT deficiency. Conclusion: The findings of this study are consistent with the concept that abnormal AAT protein conformation and intrahepatic accumulation have broad effects on metabolic liver functions. (HEPATOLOGY 2017;66:124-135) a 1 -Antitrypsin (AAT) deficiency (AATD) is one of the most common genetic disorders. The Z deficiency allele (p.Glu342Lys) of the SERPINA1 gene is present in 1 in 25 of the north European Caucasian population, of whom 1 in 2,000 to 1 in 3,500 are homozygotes.(1) The Z mutation results in deficiency of the major circulating protease inhibitor AAT predisposing to early-onset panlobular basal emphysema. Concomitantly, it causes retention of the protein within hepatocytes that is associated with neonatal hepatitis, cirrhosis, and hepatocellular carcinoma (HCC).(1,2) The natural history of liver disease due to homozygous Z allele is highly variable, and approximately 20% of homozygous ZZ newborns develop symptomatic cholestatic hepatitis.(3) Approximately 50% of ZZ infants and children are likely to develop Abbreviations: AAT, a 1 -antitrypsin; AATD, AAT deficiency; ARG1, arginase 1; ATZ, AAT encoded by the Z allele; CDH1, cadherin-1;