The most plausible explanation for this association, which has been inferred from the current understanding of NAFLD progression, would be the ‘‘two-hit’’ theory. According to this theory, the accumulation of fat in the liver is the first ‘‘hit’’, which makes the hepatocytes more vulnerable
to further damage due to certain triggers, such as IR, excess inflammation, alcohol consumption, and obesity. In this process, IR plays a central role in the vicious circle, which promotes lipolysis of the peripheral adipose tissue and increases the influx of free fatty acids into the liver. This IR
leads to hyperinsulinemia, which increases the synthesis of uric acid and decreases its renal excretion.