Background: Liver diseases in Egypt has changed from hepatitis C [after virus c eradication] to nonalcoholic fatty liver disease [NAFLD], which is described as an abundance of hepatic fat buildup [>5%] in hepatocytes determined by histology or imaging. 
Aim of the study: To evaluate the potential therapeutic benefits of Hibiscus sabdariffa L. extract in rats with non-alcoholic fatty liver disease and compare it with the effect of pioglitazone or simvastatin.
Materials and Methods: Ninety male Sprague-Dawley, weighing between 150 and 200 g [eight weeks old], were purchased from the animal house of the Pharmacology Department at the Mansoura University Faculty of Medicine. Throughout the 12 weeks of the study, rats were kept in ordinary temperature, exposed to the daily light-dark cycles, and had a free access to diet tailored according to their groups. Drugs were given from week nine to week twelve.
Results: Administration of high fructose diet increased hepatic TNF-α, MDA, TG and decreased GSH markers which usually associate fatty liver. These changes were confirmed by histopathological changes which revealed alteration of liver structure, hepatocyte ballooning, inflammation and necrotic changes with significant degrees of macro vesicular and micro vesicular steatosis. Hibiscus extract, pioglitazone and simvastatin administration improved hepatic markers and ameliorated the pathological changes by decreasing inflammation, ballooning, with partial improvement of steatosis with higher efficacy belonging to simvastatin followed by pioglitazone then Hibiscus extract. The combined drugs showed additive ameliorating effect.
Conclusion: Hibiscus, pioglitazone and simvastatin attenuated NAFLD in rat model. Hibiscus can be used as supplementary to pioglitazone and simvastatin due its safety and the additive effect of their combination.