SERPINA1 and metabolic dysfunction-associated steatotic liver disease: However, the overrepresentation of NAFLD etiology among patients harbouring the Pi∗Z allele may also be explained by the interaction between the metabolic syndrome and the Pi∗Z allele, as individuals with Pi∗ZZ and metabolic syndrome showed more accumulated abnormal AAT in hepatocytes,20 indicating that the presence of metabolic syndrome – which overlaps with NAFLD – may amplify the detrimental impact of the Pi∗Z variant.