Nonalcoholic fatty liver disease: Molecular mechanisms for the hepatic steatosis

Abstract

Liver plays a central role in the biogenesis of major metabolites including glucose, fatty acids, and cholesterol. Increased incidence of obesity in the modern society promotes insulin resistance in the peripheral tissues in humans, and could cause severe metabolic disorders by inducing accumulation of lipid in the liver, resulting in the progression of non-alcoholic fatty liver disease (NAFLD). NAFLD, which is characterized by increased fat depots in the liver, could precede more severe diseases such as non-alcoholic steatohepatitis (NASH), cirrhosis, and in some cases hepatocellular carcinoma. Accumulation of lipid in the liver can be traced by increased uptake of free fatty acids into the liver, impaired fatty acid beta oxidation, or the increased incidence of de novo lipogenesis. In this review, I would like to focus on the roles of individual pathways that contribute to the hepatic steatosis as a precursor for the NAFLD.

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pISSN 2287-2728
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http://dx.doi.org/10.3350/cmh.2013.19.3.210
Clinical and Molecular Hepatology 2013;19:210-215
Review
INTRODUCTION
In mammals, liver is a central organ for controlling the metabol-
ic homeostasis for carbohydrates, lipid, and proteins. Dysregula-
tion of liver functions could lead to the metabolic disorder that is
ultimately detrimental to the health of individuals. Recently, the
increased incidence of obesity is recognized as a major cause for
the promotion of metabolic diseases including non-alcoholic fatty
liver diseases (NAFLD), which is not only linked with other meta-
bolic diseases such as diabetes, but also invoke more severe liver
diseases including non-alcoholic steatohepatitis (NASH), hepatic
cirrhosis, and hepatocellular carcinoma (HCC).1
NAFLD can be characterized by the increased accumulation of
lipid in the liver, which can be stemmed from the multiple factors.
Increased lipolysis from the fat cells or the increased intake of di-
etary fat, followed by the enhancement of free fatty acids (FFA)
can explain this phenomenon.2 Mitochondrial dysfunction that is
associated with insulin resistance, which normally precedes the
NAFLD, could also cause lipid accumulation by impairment of fatty
acid beta oxidation.3 In addition, de novo lipogenesis in the liver
contributes greatly to the hepatic steatosis.4 Finally, reduction in
lipid clearance that is often associated with insulin resistance can
also exacerbate the condition (Fig. 1).5
Accumulation of lipid in the liver can further stimulate existing
Nonalcoholic fatty liver disease: molecular mechanisms
for the hepatic steatosis
Seung-Hoi Koo
Department of Life Sciences, Korea University, Seoul, Korea
Corresponding author : Seung-Hoi Koo
Department of Life Sciences, Korea University, 145 Anam-ro, Seongbuk-
gu, Seoul 136-713, Korea
Tel. +82-2-3290-3403, Fax. +82-2-3290-4144
E-mail; koohoi@korea.ac.kr
Abbreviations:
ACC, acetyl-CoA carboxy lase; ACOX, acyl- CoA oxidase; AMPK, AMP-activated
protein kinase; ap oB, apolipoprotein B; ChREBP, carbohydrate resp onse element
binding protein; CPT1, carnitine palmitoylt ransferase 1; DAG, diacylglycerol; DGAT,
acyl- CoA: diacylglycerol ac yltransferase; ELOVL6, long chain fatty acid elongase 6;
ER stress, endop lasmic reticulum stress; FABP, fatty a cid binding protein; FAS, fatty
acid synthas e; FAT, fatty aci d translocase; FATP, fatty acid tra nsporter protein; FFA,
free fatty acids; GPAT, glycerol-3-phosphate ac yltransferase; HCC, hepatocellular
carcinoma; HSL, hormone-s ensitive lipase; LXR alpha, live r X receptor alpha;
mTOR, mammalian target of r apamycin; NAFLD, non-alcoholic fat ty liver disease;
NASH, non-alco holic steatohepatitis; PGC-1, PPAR gamma co-activator 1; PKA,
protein kinase A; PPAR, peroxisome proliferator-activated receptor; SCD, stearoyl-
CoA desaturase; SIK s, salt inducible kinas es; SREBP-1c, sterol regulatory element
binding protein 1c; TG, trigl ycerides; VLDL, very low de nsity lipoprotein Received :
Jul. 31, 2013 /
Accepted :
Aug. 6, 2013
Liver plays a central role in the biogenesis of major metabolites including glucose, fatty acids, and cholesterol.
Increased incidence of obesity in the modern society promotes insulin resistance in the peripheral tissues in humans,
and could cause severe metabolic disorders by inducing accumulation of lipid in the liver, resulting in the progression
of non-alcoholic fatty liver disease (NAFLD). NAFLD, which is characterized by increased fat depots in the liver, could
precede more severe diseases such as non-alcoholic steatohepatitis (NASH), cirrhosis, and in some cases hepatocellular
carcinoma. Accumulation of lipid in the liver can be traced by increased uptake of free fatty acids into the liver, impaired
fatty acid beta oxidation, or the increased incidence of de novo lipogenesis. In this review, I would like to focus on the
roles of individual pathways that contribute to the hepatic steatosis as a precursor for the NAFLD. (Clin Mol Hepatol
2013;19:210-215)
Keywords: Free fatty acids; De novo lipogenesis; Fatty acid beta oxidation; TG secretion

211
Seung-Hoi Koo.
Nonalcoholic fatty liver disease: molecular mechanisms for the hepatic steatosis
http://www.e-cmh.org http://dx.doi.org/10.3350/cmh.2013.19.3.210
hepatic insulin resistance by generation of lipid-derived second
messengers such as diacylglycerol (DAG) and ceramides.6 Further-
more, lipid accumulation in the liver is also linked with the pro-
gression of endoplasmic reticulum stress (ER stress), mitochondria
stress, and impaired autophagy, resulting in the condition known
as lipotoxicity.7 This latter event can cause the immune response
in the Kupffer cells and hepatic stellate cells, which leads to the
progression of NASH, hepatic cirrhosis, and in some severe cases,
hepatocellular carcinoma.
In this review, we would like to delineate the molecular mecha-
nism for lipid accumulation in the liver as a major precursor for the
NAFLD. In particular, we will delineate the individual mechanisms
for the triglycerides (TG) synthesis and clearance that is critical in
mediating lipid homeostasis in the liver both under physiological
conditions and pathological conditions. Understanding of the mo-
lecular basis of these pathways could shed the insight into the po-
tential therapeutics in the treatment of this disease.
Fatty acids uptake
Free fatty acids (FFA) in the plasma can be taken up by the liver,
and serve as important sources for the TG synthesis in the liver.
Normally, plasma FFA is generated by white adipocytes via lipoly-
sis, which is induced by beta adrenergic receptor agonists such as
catecholamine under fasting conditions.8 This process involves the
regulation of protein kinase A (PK A)-dependent phosphorylation
and activation of hormone-sensitive lipase (HSL), a key rate limit-
ing enzyme in the lipolysis, to promote this pathway. This pathway
is reversed by insulin under feeding conditions, limiting the libera-
tion of FFA and rather inducing de novo lipogenesis in this tissue.
Upon insulin resistance that is associated with obesity, lipolysis is
hyperactivated in adipocytes, resulting in the increases in plasma
FFA.9 In addition, since obesity is often associated with increased
uptake of nutrition rich in lipid, we would expect to observe high-
er levels of precursors for TG synthesis in the liver.
The main plasma membrane transporters for FFA are fatty acid
transporter protein (FATP), caveolins, fatty acid translocase (FAT)/
CD36, and fatty acid binding protein (FABP). In mammals 6 mem-
bers of FATPs are found that contain a common motif for fatty
acid uptake and fatty acyl-CoA synthetase function.10 Among fam-
ily members, FATP2 and FATP5 are highly expressed in the liver,
and utilized as major FATPs for the normal physiological context.
Indeed, FATP5 knockout mice showed resistance to diet-induced
obesity and hepatic TG accumulation, although no clinical evi-
dence for the involvement of this FATP isoform in human obesity.11
Caveolins consist of three protein family members termed caveo-
lins 1, 2, and 3, and are found in the membrane structures called
caveolae, which are important for protein trafficking and the for-
mation of lipid droplets.12 Caveolin-1 knockout mice exhibited
lower TG accumulation in the liver and showed resistance to diet-
induced obesity, showing the importance of this protein in the TG
synthesis under obesity. FAT/CD36 is a transmembrane protein
that accelerates FA uptake via facilitated diffusion.13 Normally, this
protein is not highly expressed in the liver, but is enhanced by diet-
induced obesity. The hepatic expression of CD36 was positively
correlated with hepatic TG contents in NAFLD patients, underscor-
ing the potential importance of this transporter with this disease.14
FABPs are cytosolic lipid binding proteins that facilitate intracellu-
lar transport of FFAs.15 Among 9 isoforms, FABP1 and FABP5 are
highly expressed in the liver. Mice with liver-specific deletion of
FABP1 displayed resistance to diet-induced obesity, although he-
patic TG accumulation did not differ from that of wild type mice,
suggesting that contributions from other FABPs might be critical in
hepatic TG accumulation in this state.16 Indeed, expression of
FABP4 and FABP5 in the liver was correlated with hepatic fatty in-
filtration in NAFLD patients.17 Further study is necessary to inte-
grate roles of these fatty acid transporters in the hepatic FFA up-
take under the physiological conditions and the pathological
conditions.
Figure 1. Model for the TG accumulation in the liver in the early stage
of NAFLD. Hepatic steatosis can be stimulated via increased fatty acid
uptake, increased de novo lipogenesis, and decreased fatt y acid
oxidation followed by esterification for the TG synthesis. Additionally,
de creas es in VL DL secr eti on can also con tribut e to the lip id
accumulation in the liver. See texts for the molecular mechanisms in
detail.
Reduced
FA
oxidation
Hepatic TG
accumulation
Increased
FA
uptake (obesity)
Reduced
VLDL
secretion
De no vo
lipogenesis

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De novo lipogenesis
De novo lipogenesis is an integrated metabolic pathway that
comprises of glycolysis (conversion of glucose to acetyl-CoA), bio-
synthesis of saturated fatty acid followed by desaturation, and the
formation of TG. Key rate limiting enzymes in the process include
glucokinase and liver-type pyruvate kinase in the glycolysis, acetyl-
CoA carboxylase (ACC) and fatty acid synthase (FAS) in the fatty
acid synthesis, long chain fatt y acid elongase 6 (ELOVL6) and
stearoyl-CoA desaturase (SCD) in the formation of monounsatu-
rated fatty acids, and glycerol-3-phosphate acyltransferase (GPAT),
lipins, and acyl-CoA: diacylglycerol acyltransferase (DGAT) in the
formation of TG.18
FAS is a rate-limiting enzyme in the fatty acid biosynthesis and
catalyzes the last step in this pathway.19 Liver-specific knockout of
FAS in mice, however, displayed fatty liver phenotypes upon high
carbohydrate diet, perhaps due to the increase in hepatic malonyl-
CoA contents that would inhibit fatty acid beta oxidation.20 ACC
not only catalyzes a key rate-limiting step in the fatty acid biosyn-
thesis, but also is involved in the control of fatty acid oxidation by
synthesis of malonyl-CoA, an inhibitor for carnitine palmitoyl
transferase 1 (CPT1).21 Indeed, inhibition of liver-specific isoform
ACC1 in mice reduced hepatic TG levels in mice, by simultaneously
inhibiting fatty acid biosynthesis and activating fatty acid beta oxi-
dation in the liver.19 SCD1 is a microsomal enzyme that catalyses
the formation of monounsaturated long-chain fatty acids from
saturated fatty acyl-CoAs (E.g. conversion of palmitoyl-CoA (16:0)
to palmitoleoyl-CoA (16:1 n-7), and stearoyl-CoA (18:0) to oleoyl-
CoA (18:1 n-9)), and is predominantly expressed in the liver.22 De-
pletion of SCD1 in mice resulted in the reversal of hepatic steatosis
under western diet due to the decreased lipogenesis and increased
fatty acid beta oxidation.23 DGAT catalyzes the final step of TG
synthesis by catalyzing the acylation of diacylglycerol (DAG).24 In-
activation of hepatic isoform DGAT2 in obese mice resulted in the
significant reduction in hepatic TG contents, showing the in vivo
evidence for the importance of this protein in the de novo lipogen-
esis.25
Two major transcription factors for lipogenesis, sterol regulatory
element binding protein 1c (SREBP-1c) and carbohydrate response
element binding protein (ChREBP), are involved in the transcrip-
tional activation of genes encoding aforementioned rate-limiting
enzymes in the lipogenesis, and have been associated with in-
creased de novo lipogenesis in NAFLD.4 SREBP-1c is a member of
SREBP family that control transcriptional regulation of lipid metab-
olism.26 As ER-bound precursors, full-length SREBPs reside in the
ER by using its transmembrane domain in the middle. Transport of
SREBPs from the ER to the Golgi apparatus is mediated in part by
nutrient sensors SCAP and Insig, and the mature form of SREBPs
is generated by two consecutive proteolytic cleavages. The expres-
sion of SREBP-1c is highly induced by insulin under feeding condi-
tions and by saturated fatty acids upon high fat diet feeding in
mice, and the liver X receptor alpha (LXR alpha) is shown to be
critical in the transcriptional activation of SREBP-1c in this pro-
cess.27 The activity of SREBP-1c can be further activated by mam-
malian target of rapamycin (mTOR) pathway, while it can be inhib-
ited by PKA, AMP-activated protein kinase (AMPK), and salt
inducible kinases (SIKs).28-30 ChREBP was first identified as a regu-
lator for the hepatic glycolysis by activating transcription of L-PK
gene, and was later shown to be involved in the regulation of oth-
er lipogenic genes in the pathway.31 At low glucose conditions,
ChREBP is present in the cytosol by PK A-mediated phosphoryla-
tion, but undergoes dephosphorylation, association with its het-
erodimeric partner Mlx, and nuclear localization at high glucose
conditions, resulting in the transcriptional activation of target
genes in the liver. The additional role of AMPK in the regulation of
ChREBP was also suggested, although the exact mechanism is still
verified in vivo yet. In obese, insulin-resistant ob/ob mice, both
SREBP-1c and ChREBP are highly abundant in the liver, and reduc-
tion of either factor was shown to be beneficial in relieving hepatic
steatosis in mice, underscoring the importance of these lipogenic
transcription factors in de novo lipogenesis and the TG accumula-
tion in the liver.32,33
Fatty acid oxidative pathways
Fatty acid beta oxidation in mitochondria is a process to shorten
the fatty acids into acetyl-CoA, which can be later converted into
ketone bodies (beta hydroxybutyrate or acetoacetate) or can be
incorporated into the TCA cycle for the full oxidation.34 To initiate
the process, fatty acyl-CoAs should be transported across the mi-
tochondrial membranes by activity of a couple of CPTs. Fatty acyl-
CoAs are converted to fatty acyl-carnitines by CPT1 in the mito-
ch ondri al o uter mem brane for the transloc a tion int o the
intermembrane space. Fatty acyl-carnitines are then transported
across the mitochondrial outer membrane by carnitine acylcarni-
tine translocase. CPT2 converts fatty acyl-carnitines to fatty acyl-
CoAs for the fatty acid beta oxidation inside the mitochondrial
matrix. The first step involves the beta dehydrogenation of the ac-
yl-CoA ester by chain length-specific acyl-CoA dehydrogenases
(e.g. VLCAD, LCAD, and MCAD). Indeed, mice deficient in MCAD

213
Seung-Hoi Koo.
Nonalcoholic fatty liver disease: molecular mechanisms for the hepatic steatosis
http://www.e-cmh.org http://dx.doi.org/10.3350/cmh.2013.19.3.210
and VLCAD develop hepatic steatosis, supporting the role of these
proteins and the fatty acid beta oxidation in the hepatic TG con-
tent.35 2-enoyl-CoA hydratase, 3-hydroxyacyl-CoA dehydrogenase
and 3-oxoacyl-CoA thiolase are subsequently involved in the fatty
acid beta oxidation process to complete the conversion of acyl-
CoA ester into acetyl-CoA.
Under fasting conditions, fatty acid beta oxidation is enhanced
in part via inactivation of ACC, resulting in the reduced production
of malonyl-CoA that serves as a potent inhibitor of CPT1.21 Chronic
starvation also increases expression of beta oxidation genes via
transcriptional mechanisms. Peroxisome proliferator-activated re-
ceptor (PPAR) alpha and its co-activator PPAR gamma co-activator
1 (PGC-1) alpha are critical in enhancing expression of target
genes including CPT1, LCAD, MCAD, and acyl-CoA oxidase
(ACOX).36 Starvation-dependent activation of AMPK and sirtuins
could also enhance expression of these genes by directly modify-
ing and activating PGC-1 alpha.37,38 The clinical implication of im-
paired mitochondrial beta oxidation on the progression of NAFLD
is not conclusive, and contradicting reports have been published.
Further study is necessary to delineate the role of fatty acid beta
oxidation on hepatic lipid accumulation and the progression of
NAFLD.39
TG secretion
In the liver, TG secretion is achieved via the formation of very
low density lipoprotein (VLDL).40 VLDL consists of hydrophobic
core lipids containing TGs and cholesterol esters, which is covered
by hydrophilic phospholipids and apolipoprotein B (apoB) 100.
ApoB 100 is a liver-specific ApoB that is critical in the VLDL as-
sembly, while apoB 48 in the intestine is associated with chylomi-
cron formation. The VLDL assembly process occurs initially in the
rough ER during the translation and translocation of the apoB
100, resulting in the formation of a partially lipidated apoB 100.
The partially lipidated apoB 100, termed the pre-VLDL is then
transported into the Golgi for the maturation, and subsequently
released from the liver via exocytosis. Indeed, hepatic steatosis
was reported in patients carrying mutations in apoB 100 (hypo-
betalipoproteinemia) and in MTP (abetalipoproteinemia), under-
scoring the importance of these proteins in the lipid homeostasis
in humans.41,42
Anabolic hormone insulin is critical in the regulation of VLDL as-
sembly and secretion. Insulin plays a role in the degradation of
apoB 100, perhaps utilizing an autophagy-dependent pathway.43
Furthermore, insulin inhibits the transcription of MTP, by phospha-
tidylinositol 3 kinase/Akt-dependent regulation. Akt phosphory-
lates and inhibits transcription factor FoxA2, a critical forkhead
box factor for activating expression of MTP at the transcription
level.44,45 Upon insulin resistance, perturbation of this process re-
sults in hypertriglyceridemia via increased TG secretion. However,
the rate of TG secretion cannot keep up with the increased rate of
TG synthesis in this condition, resulting in the hepatic steatosis in
spite of the increased VLDL secretion. Similar phenotype is ob-
served in NAFLD patients, which exhibit both hypertriglyceridemia
and hepatic steatosis.4 6 Prolonged exposure of the liver to FFA
would promotes ER stress and other oxidative stress in the liver,
leading to the degradation of apoB 100, decrease in the VLDL se-
cretion, and worsening of hepatic steatosis.
CONCLUSIONS
The balance between the TG uptake/synthesis and TG hydroly-
sis/secretion is critical in the maintenance of lipid homeostasis in
the liver. Clearly, perturbation of any of these pathways could be
detrimental to the lipid metabolism. In the case of NAFLD, the
progression of hepatic steatosis can stem from the increased FFA
uptake and de novo lipogenesis for the increased TG synthesis,
and the decreased TG hydrolysis and fatty acid beta oxidation. Re-
duced TG secretion via VLDL could also promote hepatic lipid ac-
cumulation, although the VLDL secretion was rather increased in
NAFLD patients. Understanding of molecular mechanisms of each
pathway is critical in pursuing the development of therapeutics of
NAFLD in the future.
Acknowledgements
This work was supported by the National Research Foundation
of Ko r ea (g r an t nos . : NR F -2010 - 0015 09 8 an d N R F-
2012M3A9B6055345), funded by the Ministry of Science, ICT &
Future Planning, Republic of Korea, and a grant of the Korea
Health technology R&D Project (grant no : A111345), Ministry of
Health & Welfare, Korea.
Conicts of Interest
The authors have no conflicts to disclose.

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