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This process depends on: Vitamin B6 (P5P) as an essential enzyme cofactor Adequate availability of glycine and glutamate Sufficient cellular energy (ATP) Proper liver and mitochondrial function When this pathway is inefficient, glutathione production may be impaired even if homocysteine, B12, or folate levels appear normal

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However, the altering level of ATRX needs to be further tested in a larger cohort since the gene are not significantly mutated in other sequencing results except for Newells study