J Hepatol. 2022 Jun 21. pii: S0168-8278(22)00375-0. [Epub ahead of print]
Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease and emerging as the leading cause of liver cirrhosis, liver transplantation and hepatocellular carcinoma (HCC). NAFLD is a metabolic disease and considered the hepatic manifestation of the metabolic syndrome; however, during the evolution of NAFLD from steatosis to nonalcoholic steatohepatitis (NASH), to more advanced stages of NASH with liver fibrosis, the immune system plays an integral role. Triggers for inflammation are rooted in hepatic (lipid overload, lipotoxicity, oxidative stress) and extrahepatic systems (gut-liver axis, adipose tissue, skeletal muscle), resulting in unique immune-mediated pathomechanisms in NAFLD. In recent years, the implementation of single cell RNA-sequencing (scRNA-seq) and high dimensional multi-omics (proteogenomics, lipidomics) and spatial transcriptomics have tremendously advanced our understanding of the complex heterogeneity of various liver immune cell subsets in health and disease. In NAFLD, several emerging inflammatory mechanisms have been uncovered, including tremendous macrophage heterogeneity, auto-aggressive T cells, the role of unconventional T cells and platelet immune cell interactions potentially yielding novel therapeutics. In this review, we will highlight the recent discoveries related to inflammation in NAFLD, discuss the role of immune cell subsets during the different stages of the disease including disease regression and integrate the multiple systems driving inflammation. We propose a refined concept by which the immune system contributes to all stages of NAFLD and discuss open scientific questions arising from this paradigm shift that need to be unraveled in the coming years, being a basis for reliable diagnosis, prognosis of patients at risk. Finally, we discuss novel therapeutic avenues targeting the multiple triggers of inflammation, including combination therapy via nuclear receptors (FXR agonists, PPAR agonists).
Keywords: FXR agonists; HCC; Kupffer cells; NAFLD; NASH; PPAR agonists; Single-cell sequencing; cancer immunotherapy; exhausted T cells; immune-mediated liver disease; macrophages; spatial transcriptomics