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CBS utilises both haem and pyridoxal 5\u2032-phosphate (PLP) as cofactors. Although haem does not participate directly in the catalytic process, it is vital for PLP binding to the enzyme and potentially also for CBS stability. Haem deficiency can therefore undermine CBS activity by impairing PLP binding and facilitating CBS degradation. Excess haem can also impair CBS activity by inhibiting it via CO resulting from haem induction of haem oxygenase 1 (HO 1), and by induction of a functional vitamin B6 deficiency following activation of hepatic tryptophan 2,3-dioxygenase (TDO) and subsequent utilisation of PLP by enhanced kynurenine aminotransferase (KAT) and kynureninase (Kynase) activities. CBS inhibition results in accumulation of the cardiovascular risk factor homocysteine (Hcy) and evidence is emerging for plasma Hcy elevation in patients with acute hepatic porphyrias. Decreased CBS activity may also induce a proinflammatory state, inhibit expression of haem oxygenase and activate the extrahepatic kynurenine pathway (KP) thereby further contributing to the Hcy elevation. The hypothesis predicts likely changes in CBS activity and plasma Hcy levels in untreated hepatic porphyria patients and in those receiving hemin or certain gene-based therapies. In the present review, these aspects are discussed, means of testing the hypothesis in preclinical experimental settings and porphyric patients are suggested and potential nutritional and other therapies are proposed.<\/jats:p>","DOI":"10.1042\/bsr20210935","type":"journal-article","created":{"date-parts":[[2021,7,12]],"date-time":"2021-07-12T11:34:35Z","timestamp":1626089675000},"update-policy":"https:\/\/doi.org\/10.1042\/crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Multiple roles of haem in cystathionine \u03b2-synthase activity: implications for hemin and other therapies of acute hepatic porphyria"],"prefix":"10.1042","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8743-2804","authenticated-orcid":false,"given":"Abdulla\u00a0A.-B.","family":"Badawy","sequence":"first","affiliation":[{"name":"Formerly School of Health Sciences, Cardiff Metropolitan University, Western Avenue, Cardiff CF5 2YB, Wales, U.K."}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"288","published-online":{"date-parts":[[2021,7,22]]},"reference":[{"key":"2021111620501753400_B1","doi-asserted-by":"publisher","first-page":"1809","DOI":"10.1016\/j.metabol.2010.05.016","article-title":"Preliminary report: HHcy in patients with acute intermittent porphyria","volume":"59","author":"To-Figueras","year":"2010","journal-title":"Metabolism"},{"key":"2021111620501753400_B2","doi-asserted-by":"publisher","first-page":"101","DOI":"10.1016\/j.ejim.2020.04.002","article-title":"HHcy in patients with acute porphyrias: A potentially dangerous metabolic crossroad?","volume":"79","author":"Ventura","year":"2020","journal-title":"Eur. 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