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![The bidirectional relationship between fatty liver disease and COVID-19](https://image.oaes.cc/9157b8e5-7bcd-4ee3-8f7c-6eb1390afc75/202236.fig.1.jpg)
Figure 1. Mechanisms of liver damage by SARS-CoV-2 virus. SARS-CoV-2 can directly cause hepatic cytotoxicity by infecting hepatocytes. The consequent endoplasmic reticulum stress and mitochondrial stress contribute to steatosis. The hypoxic conditions arising from COVID-19 determine the activation of hypoxia-inducible factors (HIFs), exacerbating NAFLD. COVID-19 infection and PAMPs derived from the intestine cause hyperactivation of the immune system, leading to the cytokine storm syndrome, which worsens the pre-existent inflammatory state of NAFLD patients. SARS-CoV-2 can activate mTOR both directly and indirectly through the release of IL-6 during the cytokine storm syndrome. NAFLD: nonalcoholic fatty liver disease.