Individuals homozygous for the ‘‘Z’’ mutation in alpha-1 antitrypsin deficiency are known to be at increased
risk for liver disease. It has also become clear that some degree of risk is similarly conferred by the heterozygous
state. A lack ofmodel systems that recapitulate heterozygosity in human hepatocytes has limited the
ability to study the impact of a single Z alpha-1 antitrypsin (ZAAT) allele on hepatocyte biology. Here, we
describe the derivation of syngeneic induced pluripotent stem cells (iPSCs) engineered to determine the
effects of ZAAT heterozygosity in iPSC-hepatocytes (iHeps). We find that heterozygous MZ iHeps exhibit
an intermediate disease phenotype and share with ZZ iHeps alterations in AAT protein processing and
downstream perturbations including altered endoplasmic reticulum (ER) and mitochondrial morphology,
reduced mitochondrial respiration, and branch-specific activation of the unfolded protein response in cell
subpopulations. Our model of MZ heterozygosity thus provides evidence that a single Z allele is sufficient
to disrupt hepatocyte homeostatic function.