Nonalcoholic fatty liver disease (NAFLD) represents a growing cause of chronic liver injury, especially in Western Countries, where it is becoming the most frequent indication for liver transplantation (OLTx). NAFLD encompasses a spectrum of diseases that from simple steatosis (pure NAFLD) can progress to Nonalcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma (HCC). The pathogenesis of NAFLD and the mechanisms behind its progression to NASH have been extensively studied. However, while the processes that determine fat accumulation are mostly clear, the mechanisms associated with the progression of the disease are not fully characterized. In predisposed patients, lipid accumulation can promote lipotoxicity and mitochondrial dysfunction, thus triggering hepatocyte death, inflammation and fibrosis. The specific role of different lipids has been identified and free fatty acids as well as free cholesterol have been identified as toxic species. To make the picture more complex, the pathogenesis of NAFLD involves pathological connections between several organs, including the adipose tissue and the gut, with the liver. The “inflamed” adipose tissue plays a key role in the release of toxic lipids, while alterations in the gut-liver axis have been associated with the progression from NAFLD to NASH mediated by dysbiosis, alteration of intestinal barrier, and finally bacterial translocation, that can trigger proinflammatory and profibrogenetic pathways, finally leading to cirrhosis development.