73 Three chief sources of FFA are available to the hepatocyte in the IR state. The first reservoir of hepatocyte FFA is from digestion and transfers across the intestinal epithelium to hepatocytes. The second source of FFA is from digestion and transfers across the intestinal epithelium to hepatocytes, as mentioned previously. Finally, hepatocytes increase the production of FFA, a process termed de novo lipogenesis, or DNL. Studies of DGAT2 reveal that hepatocyte triglycerides may be innocuous  The concept that triglycerides may serve as a protective reservoir in the pathogenesis of

NAFLD was the result of two important studies. The first performed by Diehl and colleagues in which the ASO for the enzyme diacylglycerol acetyltransferase 2 (DGAT2) was given to db/db mice fed a methionine-choline DNA Damage inhibitor deficient diet for up to 8 weeks. Their findings were striking in that mice administrated ASO for DGAT2 had significantly higher levels of lipid peroxidation products, hepatic fibrosis and FFA, but diminished hepatocyte steatosis.74 To underscore the importance of DGAT in preventing Tamoxifen cell line both hepatocyte and systemic IR, Monetti and colleagues created mice that overexpressed

DGAT2, and found that the mice had significant steatosis and diacylglycerol but failed to develop IR indicating that hepatic steatosis arising from impaired triglyceride assembly does not result in IR.20 In vitro fat loading studies  The vast majority of proteins that a cell secretes or displays on its surface first enter the endoplasmic reticulum (ER), where they fold and assemble. Only properly assembled proteins advance from the ER to the cell surface. To ascertain fidelity in protein folding, cells regulate the protein folding capacity in the

ER according to need. The ER responds to the burden of unfolded proteins in its lumen (ER stress) by activating intracellular signal transduction pathways, collectively termed the unfolded protein response.75 Researchers have used transformed hepatocyte cell lines and have loaded cells with specific fatty acids.76–78 Saturated fatty acids, such as palmitate, or stearate, but not selleckchem oleate, resulted in increased hepatocyte apoptosis and this cell death was mediated by ER stress. These recent studies implicate the role of ER stress and the ability to discriminate between what is a normal unfolded protein response which the ER can handle without resort to cell death when the stress mechanism is overwhelmed. Czaja and colleagues clearly implicated Janus Kinase 1 (JNK1) as a principal player in driving the pathogenesis of NASH and hepatocyte apoptosis.79 Death by apoptosis is currently felt to be the major player resulting in progression of NASH.80 While this discussion cannot review the details of ER stress, the reader is referred to other sources.81–83 Three key trans-membrane proteins in the ER – PERK, ATF-4 and XBP-1 – manage misfolded proteins.