Studies over 30 years ago had demonstrated endotoxaemia in patients with chronic liver disease as a surrogate marker of increased intestinal permeability.81,82 In a recent meta-analysis summarizing 14 studies with adult and paediatric patients, an increased intestinal permeability was shown in NAFLD patients compared with healthy controls.83 Lipopolysaccharide (LPS) induces nuclear factor of activated B-cell (NF-κB) activation through binding to toll-like receptor 4 (TLR4). This evidence concerns the gene TLR4 and metabolic dysfunction-associated steatotic liver disease.