Ketogenesis mitigates metabolic dysfunction–associated steatotic liver disease through mechanisms that extend beyond fat oxidation
The progression of metabolic dysfunction-associated steatotic liver disease (MASLD) to metabolic dysfunction-associated steatohepatitis (MASH) involves alterations in both liver-autonomous and systemic metabolism that influence the liver's balance of fat accretion and disposal. Here, we quantify the contributions of hepatic oxidative pathways to liver injury in MASLD-MASH. Using NMR spectroscopy, UHPLC-MS, and GC-MS, we performed stable isotope tracing and formal flux modeling to quantify hepatic oxidative fluxes in humans across the spectrum of MASLD-MASH, and in mouse models of impaired ketogenesis. In humans with MASH, liver injury correlated positively with ketogenesis and total fat oxidation, but not with turnover of the tricarboxylic acid cycle. Loss-of-function mouse models demonstrated that disruption of mitochondrial HMG-CoA synthase (HMGCS2), the rate-limiting step of ketogenesis, impairs overall hepatic fat oxidation and induces an MASLD-MASH-like phenotype. Disruption of mitochondrial β-hydroxybutyrate dehydrogenase (BDH1), the terminal step of ketogenesis, also impaired fat oxidation, but surprisingly did not exacerbate steatotic liver injury. Taken together, these findings suggest that quantifiable variations in overall hepatic fat oxidation may not be a primary determinant of MASLD-to-MASH progression, but rather that maintenance of ketogenesis could serve a protective role through additional mechanisms that extend beyond overall rates of fat oxidation.
Authors
- Kyle Fulghum (ORCID: https://orcid.org/0000-0003-0568-3544)
- Justin R. Ryder (ORCID: https://orcid.org/0000-0002-7506-9497)
- Alisa B. Nelson (ORCID: https://orcid.org/0000-0001-7685-1803)
- Peter A. Crawford (ORCID: https://orcid.org/0000-0001-8597-4426)
- Jacob R. Gillingham (ORCID: https://orcid.org/0000-0002-6717-9960)
- Ferrol I. Rome
- Curtis C. Hughey
- Ashley S. Williams (ORCID: https://orcid.org/0000-0003-2298-2298)
- Sayeed Ikramuddin (ORCID: https://orcid.org/0000-0003-3088-7952)
- Patrycja Puchalska (ORCID: https://orcid.org/0000-0002-1875-1203)
- Scott B. Crown (ORCID: https://orcid.org/0000-0002-1983-2101)
- Patrick J. Bolan (ORCID: https://orcid.org/0000-0002-4194-3975)
- Deborah M. Muoio (ORCID: https://orcid.org/0000-0003-3760-9277)
- Eric D. Queathem (ORCID: https://orcid.org/0009-0001-7618-9554)
- David B. Stagg (ORCID: https://orcid.org/0000-0002-1044-118X)
- Alec Chaves (ORCID: https://orcid.org/0000-0002-3117-9256)
- Abdirahman Hayir
- D. André d’Avignon
- Shannon Jannatpour
Institutions
- Northwestern University (US)
- University of Minnesota (US)
- Duke University (US)
- Lurie Children's Hospital (US)
- Duke Medical Center (US)
- University of Minnesota Medical Center (US)
- Institute of Molecular Medicine (IN)
- Institute of Molecular Biology and Biophysics (RU)
- Duke University Hospital (US)
- Institute of Nutrition, Metabolism and Diabetes (CA)
Publication Details
- Journal
- Journal of Clinical Investigation
- Published
- 2025-04-24
- DOI
- https://doi.org/10.1172/jci191021
- Citations
- 11
- Primary Topic
- Diet and metabolism studies
- Type
- article
- Field-Weighted Citation Impact
- 12.81
Funders
- University of Minnesota
- National Institutes of Health
- National Heart, Lung, and Blood Institute
- National Institute of Diabetes and Digestive and Kidney Diseases