INS and metabolic dysfunction-associated steatotic liver disease: According to this theory, the pathophysiology of NAFLD consisted of a first “hit” representing the stage of simple steatosis alone (NAFL), which involves hepatocytic lipid accumulation and hepatic insulin resistance [19], as well as of a second “hit” from other factors (e.g., oxidative stress, ER stress, other injury), which was required for the development and progression of hepatic inflammation (NASH) and fibrosis.