TNF and Insulin resistance: Insulin resistance has been implicated as the first "hit" and various insults, such as oxidative stress, cytokine effects, and fatty acid toxicity are suspected as potential other hits that lead to hepatocellular injury.7 Tumor necrosis factor-alpha (TNF-α) in the liver can contribute to oxidative stress; furthermore, it may contribute to insulin resistance.8 Additionally, TNF-α also initiates fibrosis both by direct activation of hepatic stellate cells and by stimulating production of tumor growth factor (TGF)-beta, a potent profibrogenic cytokine.9