IntroductionNonalcoholic fatty liver disease (NAFLD) affects 30% of the general adult population and 70-80% of diabetic and obese patients 1 . NAFLD encompasses a histological spectrum, ranging from simple steatosis (SS) to steatosis plus necroinflammation (nonalcoholic steatohepatitis, NASH).While SS is considered to have a benign hepatological prognosis, NASH confers a 1.8-fold higher mortality, largely accounted for by liver-related complications, and is a leading cause of liver transplantation 2, 3 . Furthermore, both histological subtypes confer an increased risk of type 2 diabetes (T2DM) and cardiovascular disease (CVD) 3 .The pathogenesis of NASH is unclear: the original "two-hit" hypothesis theorized that a first "hit" , namely hepatic steatosis, determined by metabolic factors (obesity, T2DM, dyslipidemia), sensitized the liver to subsequent "second hits", namely oxidative stress and proinflammatory cytokines, that cause hepatocellular injury and liver inflammation. The validity of this view has been recently challenged, and growing evidence suggests SS and NASH may actually be 2 separate diseases: in this "multi-parallel hit" model 4 , the accumulation of "lipotoxic/pro-inflammatory" lipid species interacts with proinflammatory factors to yield NASH since the beginning, while in the other cases the liver develops steatosis and remains free from inflammatory and fibrotic changes 5 . The type of toxic lipids has been the subject of extensive research: experimental inhibition of hepatic TG synthesis 6 and human hypobetalipoproteinemia, which does not progress to cirrhosis despite massive steatosis 7 , suggested that hepatic triglyceride (Tg) accumulation is not per se toxic, but rather protects the liver by buffering the accumulation of lipotoxic Tg precursors. Consistent with this view, subjects who are able to store excessive fat as neutral cholesterol esters and TG develop steatosis but not NASH and may be considered "good fat storers", while subjects who are unable to synthesize neutral lipids acccumulate toxic lipid species and develop progressive inflammation and fibrosis, leading to NASH. The search for the key toxic lipid species then focussed on free fatty acids (FFA), diacylglycerides, phospholipids (ceramides, sphingolipids), and most recently, free cholesterol (FC) 5 . Growing evidence connects altered cholesterol homeostasis 6 and hepatic FC accumulation to the pathogenesis of NASH. In the first National Health and Nutrition Examination Survey, higher dietary cholesterol consumption independently predicted a higher risk of cirrhosis 8 , and epidemiological data connect an increased cholesterol intake to the risk and severity of NAFLD 9, 10 . In NAFLD patients, the development of NASH and fibrosis paralleled hepatic FC accumulation 11, 12 . Experimental induction of hepatic FC accumulation promoted steatohepatitis and fibrosis 13, 14, 15 , while correction of hepatic FC overload improved liver disease severity in NASH 16, 17,18,19,20, 21,22, 23 . We will review cellular mechanisms of choles...