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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

Additionally, NAD + is required for fatty acid metabolism during -oxidation, glutaminolysis generating -ketoglutarate, mitochondrial shuttling of metabolites, and lactic acid fermentation 3,4,5