Highlights d High-alcohol-producing strains of Klebsiella pneumoniae exist in humans d HiAlc Kpn is associated with NAFLD in a human cohort d Transplant of HiAlc Kpn into mice causes NAFLD d Feeding mice glucose led to detectable blood alcohol, suggesting a biomarker for NAFLD

Hexanucleotide repeat expansion in C9ORF72 is the most frequent cause of both amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Here we demonstrate that the repeat-associated non-AUG (RAN) translation of (GGGGCC)n-containing RNAs into poly-dipeptides can initiate in vivo without a 5′-cap. The primary RNA substrate for RAN translation of C9ORF72 sense repeats is shown to be the spliced first intron, following its excision from the initial pre-mRNA and transport to the cytoplasm. Cap-independent RAN translation is shown to be upregulated by various stress stimuli through phosphorylation of the α subunit of eukaryotic initiation factor-2 (eIF2α), the core event of an integrated stress response (ISR). Compounds inhibiting phospho-eIF2α-signaling pathways are shown to suppress RAN translation. Since the poly-dipeptides can themselves induce stress, these findings support a feedforward loop with initial repeat-mediated toxicity enhancing RAN translation and subsequent production of additional poly-dipeptides through ISR, thereby promoting progressive disease.

Highlights d Genome-wide CRISPR-Cas9 screens identify regulators of DPR protein production d The RNA helicase DDX3X suppresses RAN translation of C9ORF72 (GGGGCC)n repeats d Elevating DDX3X expression decreases DPR levels in C9ORF72-ALS patient cells d Elevating DDX3X rescues pathological features and improves survival of patient iPSNs