Q J Med 2010; 103:71–83

doi:10.1093/qjmed/hcp158 Advance Access Publication 13 November 2009

Review

Pathogenesis of non-alcoholic fatty liver disease

J. K. DOWMAN1,3, J.W. TOMLINSON2 and P.N. NEWSOME1,3
From the 1Centre for Liver Research, Institute of Biomedical Research, University of Birmingham,
Birmingham, B15 2TT, UK, 2Centre for Endocrinology, Diabetes & Metabolism, Institute of
Biomedical Research, University of Birmingham, Birmingham, B15 2TT, UK and
3
Birmingham Queen Elizabeth Hospital Liver Unit, Edgbaston, Birmingham, B15 2TH, UK

Address correspondence to J. K. Dowman, Centre for Liver Research, Institute of Biomedical Research,

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University of Birmingham, Wolfson Drive, B15 2TT, Birmingham, UK. email: [email protected]

Introduction NAFLD occurs in all ethnic groups although it

appears to have a lower prevalence in African-
Non-alcoholic fatty liver disease (NAFLD) represents Americans compared with Hispanic and European
a spectrum of disease ranging from hepatocellular Americans. This difference remains even after con-
steatosis through steatohepatitis to fibrosis and irre- trolling for obesity and insulin resistance (IR)5,12 and
versible cirrhosis. The prevalence of NAFLD has may be related to ethnic differences in lipid
risen rapidly in parallel with the dramatic rise in homeostasis.5
obesity and diabetes,1,2 and is rapidly becoming There are no laboratory, imaging or histological
the most common cause of liver disease in findings which can accurately distinguish between
Western countries.3 Indeed, NAFLD is now recog- NAFLD and alcohol-induced steatosis or steatohe-
nized to be the aetiology in many cases previously patitis, and the diagnosis can therefore only be
labelled as cryptogenic cirrhosis.4 made in the absence of a history of significant alco-
In Western populations, estimates of NAFLD prev- hol intake. Other specific causes of steatosis need to
alence vary between 20 and 30%,5,6 rising up to be considered and include metabolic disorders e.g.
90% in morbidly obese individuals.7 The more lipodystrophy and abetalipoproteinaemia, nutri-
tional causes such as rapid weight loss, jejuno-
severe, and clinically significant form of NAFLD,
ileal bypass and total parenteral nutrition, and
non-alcoholic steatohepatitis (NASH) is less
drug-induced. Commonly implicated agents include
common, affecting an estimated 2–3% of the gen- glucocorticoids, methotrexate, amiodarone, syn-
eral population,8 and up to 37% of the morbidly thetic oestrogens, tamoxifen, diltiazem and highly
obese.7 Of particular concern, and with significant active anti-retroviral drugs.13–15 Steatosis also com-
implications for future disease burden, is the increas- monly occurs in association with hepatitis C, partic-
ing prevalence of NAFLD in children and young ularly genotype 3, and has an increased prevalence
adults. Studies have reported a 3% prevalence of in women with polycystic ovary syndrome, when it
NAFLD in the general paediatric population, rising is usually associated with IR.16
to 53% in obese children.9,10 NAFLD has a strong In the great majority of patients NAFLD develops
association with type 2 diabetes, with steatosis pre- in association with features of IR and the metabolic
sent in 70% of type 2 diabetics screened with ultra- syndrome. The metabolic syndrome comprises a
sound,11 and thus it is now recognized to represent cluster of clinical and biochemical features,
the hepatic manifestation of the metabolic namely IR, glucose intolerance or diabetes, central
syndrome. obesity, hypertension and dyslipidaemia and is

! 2009 The Author(s)

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial
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72 J.K. Dowman et al.

associated with significant cardiovascular morbidity triglyceride accumulation may be a protective

and mortality.17–19 mechanism by preventing the toxic effects of unes-
Whilst simple steatosis in the absence of signifi- terified FFA.27 Additionally, a further component, or
cant fibrosis is considered to be a relatively benign ‘third-hit’ has been added to reflect inadequate
condition,20 the presence of fibrosis predicts both hepatocyte proliferation (Figure 1c).28 In the healthy
disease progression and liver-related complications liver, cell death stimulates replication of mature
over a subsequent 10-year period.21 Decreased sur- hepatocytes which replace the dead cells and
vival in this sub-group is due to predominantly car- reconstitute normal tissue function.28 However oxi-
diovascular causes, although there is a significant dative stress, a central feature of NAFLD pathogen-
increase in liver-related deaths.21 NASH also carries esis, inhibits the replication of mature hepatocytes
an increased risk of hepatocellular carcinoma which results in expansion of the hepatic progenitor
(HCC)21 and thus the observation of increased inci- cell (oval cell) population.29 These cells can differ-
dence of HCC in type 2 diabetics22 is likely to be entiate into hepatocyte-like cells, and both oval cell
due to their high prevalence of NASH.21 In a recent and intermediate hepatocyte-like cell numbers are
US study, NASH was found to account for at least strongly correlated with fibrosis stage, suggesting
13% of overall cases of HCC.23 that cumulative hepatocyte loss promotes both
There are as yet few proven therapies available for accumulation of progenitor cells and their differen-
patients with NASH, and current strategies are direc- tiation towards hepatocytes.29 Activation of these

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ted towards improving aspects of the metabolic syn- cells has also been implicated in hepatocellular car-
drome. Ultimately when such measures fail, liver cinogenesis.29 In chronic liver injury, the develop-
transplantation remains the only option for patients ment of fibrosis/cirrhosis is dependent on the
with end-stage cirrhosis. efficacy of hepatocyte regeneration, and therefore
Although the pathogenesis of NAFLD/NASH is cell death with impaired proliferation of hepatocyte
not yet fully understood, much progress has been progenitors represents the proposed ‘third hit’ in
made in recent years in elucidating the mechanisms NAFLD pathogenesis.28
of progression from steatosis to more advanced liver
inflammation and fibrosis. In this review, we discuss Lipid accumulation/steatosis
the current understanding of NAFLD pathogenesis,
and anticipate that such knowledge will eventually NAFLD is characterized by the accumulation of tri-
translate into the development of novel treatment glycerides, which are formed from the esterification
strategies for this increasingly important disease. of FFA and glycerol within the hepatocyte. FFAs
arise in the liver from three distinct sources; lipolysis
(the hydrolysis of FFA and glycerol from triglyceride)
within adipose tissue, dietary sources, and de novo
lipogenesis (DNL).30 In contrast, FFA may be uti-
NAFLD pathogenesis lized either through b-oxidation, re-esterification to
The ‘2-hit hypothesis’ triglycerides and storage as lipid droplets, or pack-
aged and exported as very low density lipoprotein
Initial theories for the pathogenesis of NASH were (VLDL). Hence hepatic fat accumulation can occur
based on a ‘2-hit hypothesis’ (Figure 1a). The ‘first as a result of increased fat synthesis, increased fat
hit’, hepatic triglyceride accumulation, or steatosis, delivery, decreased fat export, and/or decreased fat
increases susceptibility of the liver to injury oxidation (Figure 2).30
mediated by ‘second hits’, such as inflammatory To establish the relative contribution of lipid
cytokines/adipokines, mitochondrial dysfunction accumulation in patients with NAFLD, Donnelly
and oxidative stress, which in turn lead to steatohe- et al. used a multiple-stable-isotope method,
patitis and/or fibrosis.24,25 However, there is increas- demonstrating that approximately 60% of liver tri-
ing recognition of the role that free fatty acids (FFA) glyceride content derived from FFA influx from adi-
play in directly promoting liver injury, which has led pose tissue, 26% from DNL, and 15% from diet.31
to modification of this theory (Figure 1b). In obesity This contrasts with healthy individuals in whom
and IR there is an increased influx of FFA to the liver. DNL contributes <5% of hepatic triglyceride
These FFA either undergo b-oxidation or are ester- formation.32,33
ified with glycerol to form triglycerides, leading to Triglyceride can also be exported from the liver in
hepatic fat accumulation. There is now substantial VLDL particles, which are formed by the incorpora-
evidence that FFA can directly cause toxicity by tion of triglyceride into apolipoprotein B (apoB) by
increasing oxidative stress and by activation of microsomal transfer protein (MTP).34 Aberrant
inflammatory pathways,26 therefore hepatic alterations of MTP/apoB synthesis and secretion
 Pathogenesis of non-alcoholic fatty liver disease 73

(a) Obesity and Inflammatory Adipokine

insulin resistance cytokines eg. imbalance
Diet TNFα, IL-6

Gut-derived
↑FFA endotoxin
ER stress

De novo
lipogenesis

Steatosis NASH / Fibrosis

FFA TAG

Oxidative
stress /
mitochondrial
dysfunction

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1st hit - steatosis 2nd hit –inflammation / fibrosis

(b)
Obesity and
insulin resistance Oxidative
Diet Gut-derived Adipokine
stress / endotoxin imbalance
mitochondrial
dysfunction
↑FFA

De novo
lipogenesis

TAG
(protective)
FFA NASH / Fibrosis

ER stress
Lipotoxicity
IKKβ /
NFKβ
activation
Inflammatory
cytokines eg.
1st hit -steatosis TNFα, IL-6 2nd hit – inflammation / fibrosis

Figure 1. (a) The traditional 2-hit hypothesis: steatosis represents the ‘first hit’, which then sensitises the liver to injury
mediated by ‘second hits’, such as inflammatory cytokines, adipokines, oxidative stress and mitochondrial dysfunction,
leading to steatohepatitis and fibrosis. The presence of high levels of oxidative stress reduces the ability of mature hepato-
cytes to proliferate, resulting in reduced endogenous liver repair. (b) Modified 2-hit hypothesis: the accumulation of FFA
alone has been suggested to be sufficient to induce liver damage, without recourse for a second hit. Indeed, rather than being
harmful, triglyceride accumulation in the form of steatosis may actually be protective by preventing FFA-induced inflam-
mation and oxidative stress. (c) The 3-hit hypothesis: oxidative stress reduces the ability of mature hepatocytes to proliferate,
resulting in the recruitment of other pathways of liver regeneration, such as HPCs. These cells have the capability of
differentiating into both cholangiocytes and hepatocytes and contributing to liver repair. It has been suggested that an
inability to mount such a ductular response, as is seen in patients transplanted for NASH who have denervated livers,
may be responsible for a more progressive pattern of liver damage. Thus, impaired proliferation of hepatocyte progenitors
represents the proposed ‘third hit’ in NAFLD pathogenesis.28
74 J.K. Dowman et al.

(c) Obesity and

Oxidative
insulin resistance Adipokine
stress / Gut-derived
Diet imbalance
mitochondrial endotoxin
dysfunction

↑FFA
ER
stress
De novo
lipogenesis

TAG
NASH / Fibrosis
FFA

Lipotoxicity IKKβ /
NFKβ
activation inadequate cell
Inflammatory

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regeneration
cytokines eg. Hepatocyte
TNFα, IL-6 death

1st hit -steatosis 2nd hit – inflammation / fibrosis 3rd hit – hepatocyte death

Figure 1. Continued.

Insulin resistance
effects of insulin.30 Ultimately, AKT/PKB activation
Hyperglycaemia/hyperinsulinaemia results in translocation of glucose transporter,
GLUT4, containing vesicles to the plasma mem-
Adipose tissue
↑ De novo lipogenesis brane, thus facilitating glucose uptake. In addition,
STEATOSIS
the expression of key lipogenic genes is increased,
↑ FFA Triglyceride
synthesis with a concomitant decrease in gluconeogenic gene
expression via its regulation of forkhead (FOXO)
transcription factor activity.
↓ β-oxidation
Insulin has a potent action to suppress adipose
tissue lipolysis. However, in situations of IR, such
VLDL as NAFLD, this suppression is impaired resulting in
an increased efflux of FFA from adipose tissue.38
Excess dietary lipids The hyperinsulinaemia associated with IR leads to:
(i) up-regulation of the transcription factor sterol reg-
Figure 2. Mechanisms of hepatic fat accumulation.
ulatory element binding protein-1c (SREBP-1c),
which is a key transcriptional regulator of genes
have been proposed as potential mechanisms involved in DNL,15 and (ii) Inhibition of b-oxidation
underpinning the pathogenesis of NAFLD leading of FFA thus further promoting hepatic lipid
to a decreased capacity for lipid export.35,36 accumulation.30
Many of the abnormalities reported in NAFLD
interfere with the insulin signalling cascade, and
Insulin resistance thus contribute to IR. These include FFAs,
In healthy individuals, binding of insulin to its recep- tumour necrosis factor-alpha (TNF-a), nuclear
tor leads to phosphorylation of several substrates factor kappa B (NF-kB), ceramide, jun N-terminal
including insulin receptor substrates (IRS)-1, -2, -3 kinase 1 (JNK1), SOCS (suppressors of cytokine
and -4, which propagate the insulin signal.30,37 signalling) and cytochrome CYP2E1.39,40 Increased
Insulin stimulation of IRS-1 and -2 leads to activa- lipid metabolites such as diacylglycerol (DAG) have
tion of intracellular PI3K (phosphoinositide 3-kinase) been implicated in a protein kinase Ce
and AKT/PKB (protein kinase B) pathways, which (PKCe) dependent mechanism, to interfere with
are intimately involved in mediating the metabolic insulin signalling through inhibition of insulin
 Pathogenesis of non-alcoholic fatty liver disease 75

Inflammation / cell injury

Insulin resistance

↑ TNF-α, IL-6, IL-1β

↑ Leptin, Gut-derived
↓ Adiponectin endotoxin
↑ Osteopontin

NASH /
IKK-B / ↑ TNF-α, IL-6,
↑ FFA IL-1B
Cirrhosis
Expanded ↑ Hepatic oxidation/ NF-KB
adipose FFA oxidative activation
tissue stress

Local steroid
excess
(↑11BHSD1 ER stress Fibrosis Hepatocellular
carcinoma

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and ↑5aR
activity)

↑ Leptin
↓ Adiponectin Inflammatory cytokines / adipokines and FFA
↑ Angiotensinogen Oxidative stress / mitochondrial dysfunction
↑ Norepinephrine Local glucocorticoid excess
↑ Osteopontin Gut-derived endotoxin/ bacterial overgrowth

Figure 3. Proposed pathogenesis of NASH. The likelihood of progression to advanced NASH/cirrhosis results from a com-
plex interplay between genetic predisposition and the mechanisms described earlier.

receptor activity and modulation of IRS-2 protective measure to prevent direct hepatic lipo-
phosphorylation.30 Similar processes occur in skel- toxicity. This is endorsed by a murine model of
etal muscle cells, leading to a more generalized NAFLD, where inhibition of DGAT2, the enzyme
state of IR. that catalyzes the final step in triglyceride synthesis,
resulted in improvement of hepatic steatosis and IR
Inflammation/steatohepatitis but exacerbation of injury and fibrosis.27,42
Both serum and hepatic levels of TNF-a are ele-
Inflammatory cytokines and FFA vated in patients with NASH,43,44 and levels corre-
The presence of steatosis is tightly associated with late with histological severity.45 In addition to its
chronic hepatic inflammation,41 an effect in part proinflammatory effects, TNF-a promotes IR.46
mediated by activation of the Ikk-b/NF-kB signalling Conversely, inhibition of TNF-a signalling improves
pathway. In murine models of high-fat diet (HFD)- IR and histological parameters of NASH.47–49
induced steatosis, increased NF-kB activity is Similarly, serum IL-6 levels are also elevated in
associated with elevated hepatic expression of both animal and human models of IR and
inflammatory cytokines such as TNF-a, interleukin- NAFLD,43,50,51 and levels correlate with increasing
6 (IL-6) and interleukin 1-beta (IL-1b), and activation liver inflammation and fibrosis.52 The key role of
of Kupffer cells.41 Liver-specific NF-kB inhibition hepatocyte cytokine production in the progression
prevents HFD-induced inflammatory gene expres- of steatosis to NASH is supported by studies demon-
sion, whereas HFD-induced hyperglycaemia and strating that cytokines can replicate all of the histo-
IR can be reproduced by selective over-expression logical features associated with NASH, including
of constitutively active Ikk-b in hepatocytes.41 The neutrophil chemotaxis, hepatocyte apoptosis/necro-
Ikk-b/NF-kB pathway in hepatocytes can also be sis, Mallory body formation and stellate cell activa-
activated directly by FFA, providing a further mech- tion.25 Additionally, data suggests that inflammation
anism by which central obesity with consequent and NF-kB activation can promote carcinogen-
increased hepatic FFA supply can contribute to esis,53 and that the chronic inflammatory state asso-
inflammation (Figure 3).26 Furthermore, the conver- ciated with hepatic steatosis may also play a key
sion of FFA to hepatic triglyceride may serve as a role in HCC development.25
76 J.K. Dowman et al.

Adipokines NASH and represents a potent source of ROS.75,76

Adipose tissue is not just an inert site of energy stor- Importantly, transgenic over-expression of CYP2E1
age, but an actively secreting endocrine organ. activity is associated with oxidative stress, IR and
The functional role of adipocyte-derived cytokines hepatic fat accumulation.77
(adipokines), is now increasingly recognized, with
leptin and adiponectin amongst the most well ER stress and bacterial overgrowth
described. Leptin is a 16 kDa hormone produced Other mechanisms implicated in NASH pathogen-
mainly by mature adipocytes whose actions include esis include endoplasmic reticulum (ER) stress and
the regulation of energy intake and expenditure,54 gut-derived endotoxinaemia.25 ER stress can be
regulation of the immune system,55,56 and promo- caused by a variety of biological stresses, including
tion of inflammation and fibrogenesis.56,57 Higher hyperinsulinaemia and hyperlipidaemia,25,78 and
leptin levels are observed in obese patients and can result in activation of various pathways leading
those with NAFLD,54,58–60 which are commonly to IR, inflammation, apoptosis and mitochondrial
regarded as states of leptin resistance.58 It remains dysfunction. ER stress is known to be important in
plausible that leptin may have a functional role to alcohol-induced steatohepatitis and further study of
play in the pathogenesis of NAFLD. its role in NASH is warranted.25
In contrast to leptin, secretion and circulating Evidence is also emerging for a role of bacterial

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levels of adiponectin are inversely proportional overgrowth in the pathogenesis of NASH. Bacterial
to body fat content,61 and are reduced in patients overgrowth results in production of ethanol79 and
with NAFLD.44,62 Adiponectin is anti-inflammatory release of bacterial lipopolysaccharides, both of
and increases insulin sensitivity,63 and the adminis- which can activate TNF-a production in Kupffer
tration of recombinant adiponectin improves hepa- cells and thus induce hepatic inflammation.80
tomegaly, as well as the biochemical and Small intestinal bacterial overgrowth and increased
histological parameters of NAFLD in a murine gut permeability have been found more frequently
model.64,65 Adiponectin antagonises the effects in patients with NASH when compared with con-
of TNF-a, which itself suppresses adiponectin pro- trols.81,82 This has led to the suggestion that this may
duction.61 The importance of adiponectin in explain the onset of NASH and liver fibrosis as a
NAFLD is supported by studies showing that complication of jejunoileal bypass surgery.83,84
serum adiponectin levels can help to distinguish This hypothesis is further supported by evidence
NASH from simple steatosis.44,66,67 Other adipose that alteration of gut flora with antibiotics85 and pro-
tissue derived factors found in excess in NAFLD biotics49,86,87 can reduce hepatic inflammation in
include TNF-a, IL-6, angiotensinogen and both animals and humans.
resistin, all of which antagonise the lipogenic
effects of insulin,28 but their precise role in the Glucocorticoids
pathogenesis of NAFLD remains to be determined
GCs from both exogenous and endogenous sources
(Figure 3).
are a well-recognized cause of NAFLD. Patients
with Cushing’s syndrome, who have increased cir-
Oxidative stress and mitochondrial dysfunction culating GC levels develop a characteristic meta-
The role of oxidative stress and mitochondrial dys- bolic phenotype of central obesity, IR and
function in NASH is well-established, with more diabetes. Importantly, a significant proportion of
advanced disease correlating with greater degrees these patients will also develop hepatic steatosis.88
of oxidative stress.68–71 b-oxidation within the The mechanisms by which GCs promote hepatic fat
normal liver takes place in the mitochondria, but accumulation include inhibition of fatty acid
in the context of NAFLD72 this process can b-oxidation and promotion of hepatocyte DNL.
become overwhelmed as a result of increased FFA However most patients with NAFLD have normal
load, giving rise to reactive oxygen species (ROS).71 circulating cortisol levels, suggesting that tissue-
ROS induce oxidative stress, with subsequent acti- specific mechanisms are driving the metabolic
vation of inflammatory pathways,73 and also mito- dysfunction.
chondrial damage. Structural mitochondrial This has led to emerging interest in two enzyme
abnormalities71 and a reduction in mitochondrial systems which play a key role in local GC metabo-
respiratory chain activity have been observed in lism and consequent GC availability to bind and
human studies of NASH.74 Elevated expression activate the GC receptor. 11b-hydroxysteroid dehy-
and activity of the hepatic microsomal fatty acid drogenase type 1 (11b-HSD1) converts inactive cor-
oxidizing enzyme cytochrome P450 2E1 (CYP2E1) tisone to the active GC cortisol,89 and thus increases
has been observed in human and animal models of local GC levels and amplifies GC action. Inhibition
 Pathogenesis of non-alcoholic fatty liver disease 77

of 11bHSD1 has been shown to lower body weight denervated livers, may be responsible for a more
and lipid levels and improve glucose tolerance in progressive pattern of liver damage.
animal models,90 and increase hepatic insulin sen- Controversy continues to exist in the literature
sitivity in humans.91,92 about the interplay of the ductular reaction and
In parallel, the A-ring reductase enzymes, 5-a- fibrosis in NAFLD. Initial work demonstrated a
and 5-b reductase, are responsible for the metabo- close association between the expansion of HPCs
lism of cortisol to its inactive tetrahydrometabolites. and the ductular reaction in liver biopsy specimens
Increased hepatic 5-a reductase (5aR) activity of NASH. The extent of ductular reactions in turn
has been demonstrated in patients with IR89 and strongly correlated with the degree of fibrosis, sug-
NAFLD,93 which may represent a compensatory gesting that HPC expansion/ductular reaction may
mechanism to decrease local GC availability in an be responsible for stimulating a progressive peripor-
attempt to prevent development or progression of tal fibrosis.98 Possible mechanisms for this include
NAFLD. In animal models, both pharmacological the secretion of profibrogenic cytokines (TGF-b, IL6,
and transgenic inhibition of 5aR activity has been IL8 and MCP1) by the ductular reaction,99 as well as
shown to increase susceptibility to development of direct epithelial mesenchymal transition of the cho-
IR and fatty liver.94 Hence reduction of local hepatic langiocytes to myofibroblasts.100 This hypothesis is
GC exposure by modulation of 11bHSD1 and the A- attractive in that it provides a rationale for the gen-
ring reductases may represent a potential therapeu- eration of portal fibrosis in NAFLD which is a key

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tic intervention for preventing the development and feature of progressive disease. More recent work in
progression of NAFLD. the CDE model of murine NAFLD has suggested that
liver fibrosis precedes the proliferation of HPCs, sug-
Fibrosis gesting that fibrosis does not occur purely as a result
of HPC expansion.101 The timing of the presence of
Fibrosis, and its more advanced form cirrhosis, the differing histological findings is less clear on fur-
represents the final common pathway of almost all ther evaluation,102 raising the possibility of an alto-
chronic liver diseases including NASH. Advanced gether more complex interaction between fibrosis
fibrosis results in liver failure and portal hyperten- and HPC expansion, in which both cellular pro-
sion with its associated complications of ascites and cesses can stimulate each other respectively.
life-threatening variceal bleeding, as well as an Indeed, the creation of a progenitor cell niche,
increased risk of HCC. The pathogenesis of fibrosis with deposition of matrix, may act not only as a
is not within the remit of this review and is well migratory pathway for HPCs to migrate along
covered elsewhere.95 from the portal tract into the parenchyma, but also
There are certain aspects of liver fibrosis and provide trophic factors for the survival of these
repair which are relatively specific to NASH and cells.103
are worth considering here. In most conditions of
liver injury repair arises by replication of mature
hepatocytes,96 however the presence of ongoing
Genetic predisposition
injurious factors such as NASH or viral infection, is Although hepatic steatosis is common in patients
associated with high levels of oxidative stress which with obesity and IR only a minority progress to
reduce the ability of these mature hepatocytes to NASH and cirrhosis, suggesting an important inter-
proliferate. In this situation, other pathways of liver play between genetic predisposition and environ-
regeneration, hepatic progenitor cells (HPCs), are mental factors.72 Polymorphisms in genes related
recruited. HPCs are transit-amplifying cells which to lipid metabolism, IR, oxidative stress, cytokines/
reside in the Canal of Hering, and which on prolif- adipokines and fibrogenesis may all increase sus-
eration form a complex of small ductules and cho- ceptibility to NASH development.104 Several studies
langiocytes known as a ductular reaction. This term have identified single nucleotide polymorphisms
was first used to identify the expanded population of (SNPs) which influence fibrosis development in
epithelial cells at the interface of the biliary tree and other liver diseases, particularly chronic hepatitis
the hepatocytes, and refers to proliferation of pre- C.105–107 Studies in NASH have so far demonstrated
existing ductules, progenitor cell activation and polymorphisms in the angiotensinogen and TGF-b1
appearance of intermediate hepatocytes.97 genes to be associated with advanced hepatic fibro-
Subsequently these cells have the capability of dif- sis in obese patients.108 In addition, SNPs in the
ferentiating into both cholangiocytes and hepato- angiotensin II type 1 receptor are associated with
cytes and contributing to liver repair. An inability an increased risk of NAFLD and NAFLD-related
to mount such a ductular response, as is seen in fibrosis.109 Further studies are needed to identify
patients transplanted for NASH who have more candidate genes which will undoubtedly be
78 J.K. Dowman et al.

informative not only as to the pathogenesis and proliferator activated receptor gamma (PPARg).
prognosis of the disease, but also may represent Studies have demonstrated that PPARg ligation by
novel treatment targets. PPARg agonists, such as the thiazolidinediones
(Rosiglitazone and Pioglitazone), leads to reduced
HSC activation. Encouraging results with these
Current and emerging therapies agents have been demonstrated in patients with
NAFLD with improvements in both liver biochemis-
Current therapies try and histology.123–125 However side-effects
Despite an increasing understanding of the mechan- including congestive cardiac failure,126 osteoporo-
isms of NAFLD pathogenesis, there are few effective sis127 and weight gain125 are of concern. Benefits
therapies available. Current treatments are primarily also appear to be reversed on discontinuation of
directed towards improving the metabolic para- therapy.128
meters which contribute to disease pathogenesis, Angiotensin has been shown to promote myofi-
such as weight loss and exercise, reducing IR and broblast survival and liver fibrosis,129 and thus the
improving diabetic control. beneficial effects of ACE inhibitors and angiotensin
In addition to lifestyle changes, current therapies receptor blockers (ARBs) are likely to include anti-
utilized for patients with NAFLD include insulin sen- fibrotic properties. Several clinical studies of antiox-
idants such as vitamin E, which have been shown to

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sitizers, e.g. metformin and the thiazolidinediones,
weight loss drugs, e.g. orlistat and sibutramine, and suppress fibrosis in vitro, have so far failed to dem-
consideration of bariatric surgery for morbidly obese onstrate that dietary supplementation of vitamin E
patients. Liver transplantation remains the only cura- improves histological fibrosis in humans.110,111 A
tive treatment option for end-stage cirrhosis. large number of cytokines are intimately involved
The urgent need for specific treatments for NAFLD in the proliferative, contractile and fibrogenic activ-
has rendered this a critical area of research, with ities of HSCs, antagonism of which represents
particular focus on developing treatments which another potential target for antifibrotic therapies.130
can reverse or prevent the more advanced and clin- Potential candidates include platelet-derived growth
ically relevant stages of NASH. The presence of factor (PDGF), transforming growth factor beta-1
fibrosis predicts likelihood of liver related complica- (TGFb-1),130 connective tissue growth factor
tions and therefore therapies which can prevent or (CTGF),131 endothelin-1 (ET-1), thrombin, vascular
reverse fibrosis are important goals. endothelial growth factor (VEGF), fibroblast growth
factor and insulin-like growth factor, which also
exert their effects through tyrosine-kinase recep-
New and emerging therapies tors.130 Consistent with this, studies in animal
Therapies currently undergoing evaluation in NASH models of liver fibrosis have demonstrated antifibro-
include antioxidants, such as vitamins C, E110,111 tic effects using tyrosine kinase inhibitors such as
and betaine,112 iron depletion,113 ursodeoxycholic imatinib132,133 which is currently licensed for use
acid,114,115 statins116–118 and pentoxifylline.47,119 in chronic myeloid leukaemia and gastrointestinal
Whilst none of these treatments has yet shown con- stromal tumours.
vincing evidence of benefit, further trials are Other potential targets alluded to earlier include
ongoing. inhibiting ER stress,134 and modulation of the gut
Glucagon-like peptide-1 (GLP-1)-based therapy liver axis using pre- and probiotics.49,85–87,135
may represent a novel therapeutic option for slow-
ing the progression of NAFLD. In diabetic patients
GLP-1 analogues, such as Exenatide, have been Conclusions
shown to increase insulin secretion, suppress gluca-
gon secretion, slow gastric emptying and increase NAFLD now represents one of the commonest
satiety in association with modest weight loss,120 causes of liver disease in the Western world, and
and in animal models GLP-1 agonists reduced IR, the rising levels of obesity, diabetes and metabolic
markers of oxidative stress and hepatic steatosis.121 syndrome will ensure that it remains a major cause
of morbidity and mortality. Although simple steato-
sis carries a relatively benign prognosis, a significant
Antifibrotic therapies proportion of patients will progress to NASH and
Hepatic fibrosis is the product of hepatic myofibro- later cirrhosis with risk of HCC.
blasts which predominantly arise from activation of The traditional ‘2-hit’ hypothesis of NAFLD patho-
hepatic stellate cells (HSCs), that reside in the space genesis has been modified several times; in most
of Disse.122 HSCs express the nuclear peroxisome patients however NAFLD does appear to begin
 Pathogenesis of non-alcoholic fatty liver disease 79

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Brown AJ. Nonalcoholic steatohepatitis and nonalcoholic
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Conflict of interest: None declared. syndrome. J Clin Endocrinol Metab 2006; 91:1741–7.
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