Title: Comparative Study of Ultrasound Attenuation Analysis and Controlled Attenuation
Parameter in the Diagnosis and Grading of Liver Steatosis in Non-alcoholic Fatty Liver Disease
Patients
Version: 0 Date: 21 Jan 2024
Reviewer's report:
In the Method section, please specify the third exclusion criteria for NAFLD participants: use
of fat-preparation.
Error factors that may influence the ultrasound elastography technique, the Controlled
Attenuation Parameter (CAP) used have been excluded? Conditions as: cytolysis, cholestasis,
congestion, amyloidosis, lymphomas, and extramedullary hematopoiesis were not mentioned in
the exclusion criteria, although they may alter the results of the CAP.  Were the patients included
evaluated by CAP outside of episodes of cytolysis or cholestasis?
In the Discussion section discuss more on the accuracy and cutoff values. Compare the cutoff
values of your study with the optimal cutoffs established in meta-analyses for the prediction
of mild (S1), moderate (S2), and severe (S3) steatosis. The cut-off values were established at
248 dB/m, (AUC 0.823, Se 68.8%, Sp 82.2%), 268 dB/m, (AUC 0.865, Se 77.3%, Sp 81.2%),
and 280 dB/m (AUC 0.882, Se 88.2%, Sp 77.6%) for detecting steatosis #S1, #S2, and S3,
respectively.
- Karlas T., Petroff D., Sasso M., Fan J.G., Mi Y.Q., de Lédinghen V., Kumar M., Lupsor-
Platon M., Han K.H., Cardoso A.C., et al. Individual patient data meta-analysis of controlled
attenuation parameter (CAP) technology for assessing steatosis. J. Hepatol. 2017;66:1022–1030.
doi: 10.1016/j.jhep.2016.12.022).
- Lup#or-Platon M, Feier D, Stefanescu H, Tamas A, Botan E, Sparchez Z, Maniu A, Badea R.
Diagnostic accuracy of controlled attenuation parameter measured by transient elastography for
the non-invasive assessment of liver steatosis: a prospective study. J Gastrointestin Liver Dis.
2015; 24:35–42.
It is suggested that these cut-offs should be further adapted for particular settings as they were
influenced by several covariates. Specifically, it was suggested that practitioners should deduct
10 dB/m from the CAP value for NAFLD/NASH patients, deduct 10 dB/m for diabetes patients,
and deduct/add 4.4 dB/m for each unit of BMI above/below 25 kg/m2 over the range of 20–
30 kg/m2.
- Taru MG, Neamti L, Taru V, Procopciuc LM, Procopet B, Lupsor-Platon M. How to
Identify Advanced Fibrosis in Adult Patients with Non-Alcoholic Fatty Liver Disease (NAFLD)
and Non-Alcoholic Steatohepatitis (NASH) Using Ultrasound Elastography-A Review of the
Literature and Proposed Multistep Approach. Diagnostics (Basel). 2023 Feb 19;13(4):788. doi:
10.3390/diagnostics13040788. PMID: 36832276; PMCID: PMC9955630.
-  Petroff D, Blank V, Newsome PN, et al. Assessment of hepatic steatosis by controlled
attenuation parameter using the M and XL probes: an individual patient data meta-analysis.
Lancet Gastroenterol Hepatol. 2021; 6:185–198.
Your references should be updated.
Title: Comparative Study of Ultrasound Attenuation Analysis and Controlled Attenuation
Parameter in the Diagnosis and Grading of Liver Steatosis in Non-alcoholic Fatty Liver Disease
Patients
Version: 0 Date: 21 Jan 2024
Reviewer's report:
In the Method section, please specify the third exclusion criteria for NAFLD participants: use
of fat-preparation.
Error factors that may influence the ultrasound elastography technique, the Controlled
Attenuation Parameter (CAP) used have been excluded? Conditions as: cytolysis, cholestasis,
congestion, amyloidosis, lymphomas, and extramedullary hematopoiesis were not mentioned in
the exclusion criteria, although they may alter the results of the CAP.  Were the patients included
evaluated by CAP outside of episodes of cytolysis or cholestasis?
In the Discussion section discuss more on the accuracy and cutoff values. Compare the cutoff
values of your study with the optimal cutoffs established in meta-analyses for the prediction
of mild (S1), moderate (S2), and severe (S3) steatosis. The cut-off values were established at
248 dB/m, (AUC 0.823, Se 68.8%, Sp 82.2%), 268 dB/m, (AUC 0.865, Se 77.3%, Sp 81.2%),
and 280 dB/m (AUC 0.882, Se 88.2%, Sp 77.6%) for detecting steatosis #S1, #S2, and S3,
respectively.
- Karlas T., Petroff D., Sasso M., Fan J.G., Mi Y.Q., de Lédinghen V., Kumar M., Lupsor-
Platon M., Han K.H., Cardoso A.C., et al. Individual patient data meta-analysis of controlled
attenuation parameter (CAP) technology for assessing steatosis. J. Hepatol. 2017;66:1022–1030.
doi: 10.1016/j.jhep.2016.12.022).
- Lup#or-Platon M, Feier D, Stefanescu H, Tamas A, Botan E, Sparchez Z, Maniu A, Badea R.
Diagnostic accuracy of controlled attenuation parameter measured by transient elastography for
the non-invasive assessment of liver steatosis: a prospective study. J Gastrointestin Liver Dis.
2015; 24:35–42.
It is suggested that these cut-offs should be further adapted for particular settings as they were
influenced by several covariates. Specifically, it was suggested that practitioners should deduct
10 dB/m from the CAP value for NAFLD/NASH patients, deduct 10 dB/m for diabetes patients,
and deduct/add 4.4 dB/m for each unit of BMI above/below 25 kg/m2 over the range of 20–
30 kg/m2.
- Taru MG, Neamti L, Taru V, Procopciuc LM, Procopet B, Lupsor-Platon M. How to
Identify Advanced Fibrosis in Adult Patients with Non-Alcoholic Fatty Liver Disease (NAFLD)
and Non-Alcoholic Steatohepatitis (NASH) Using Ultrasound Elastography-A Review of the
Literature and Proposed Multistep Approach. Diagnostics (Basel). 2023 Feb 19;13(4):788. doi:
10.3390/diagnostics13040788. PMID: 36832276; PMCID: PMC9955630.
-  Petroff D, Blank V, Newsome PN, et al. Assessment of hepatic steatosis by controlled
attenuation parameter using the M and XL probes: an individual patient data meta-analysis.
Lancet Gastroenterol Hepatol. 2021; 6:185–198.
Your references should be updated.
Please review this paper.
user
Title: Comparative Study of Ultrasound Attenuation Analysis and Controlled Attenuation
Parameter in the Diagnosis and Grading of Liver Steatosis in Non-alcoholic Fatty Liver Disease
Patients
Version: 0 Date: 21 Jan 2024
Reviewer's report:
In the Method section, please specify the third exclusion criteria for NAFLD participants: use
of fat-preparation.
Error factors that may influence the ultrasound elastography technique, the Controlled
Attenuation Parameter (CAP) used have been excluded? Conditions as: cytolysis, cholestasis,
congestion, amyloidosis, lymphomas, and extramedullary hematopoiesis were not mentioned in
the exclusion criteria, although they may alter the results of the CAP.  Were the patients included
evaluated by CAP outside of episodes of cytolysis or cholestasis?
In the Discussion section discuss more on the accuracy and cutoff values. Compare the cutoff
values of your study with the optimal cutoffs established in meta-analyses for the prediction
of mild (S1), moderate (S2), and severe (S3) steatosis. The cut-off values were established at
248 dB/m, (AUC 0.823, Se 68.8%, Sp 82.2%), 268 dB/m, (AUC 0.865, Se 77.3%, Sp 81.2%),
and 280 dB/m (AUC 0.882, Se 88.2%, Sp 77.6%) for detecting steatosis #S1, #S2, and S3,
respectively.
- Karlas T., Petroff D., Sasso M., Fan J.G., Mi Y.Q., de Lédinghen V., Kumar M., Lupsor-
Platon M., Han K.H., Cardoso A.C., et al. Individual patient data meta-analysis of controlled
attenuation parameter (CAP) technology for assessing steatosis. J. Hepatol. 2017;66:1022–1030.
doi: 10.1016/j.jhep.2016.12.022).
- Lup#or-Platon M, Feier D, Stefanescu H, Tamas A, Botan E, Sparchez Z, Maniu A, Badea R.
Diagnostic accuracy of controlled attenuation parameter measured by transient elastography for
the non-invasive assessment of liver steatosis: a prospective study. J Gastrointestin Liver Dis.
2015; 24:35–42.
It is suggested that these cut-offs should be further adapted for particular settings as they were
influenced by several covariates. Specifically, it was suggested that practitioners should deduct
10 dB/m from the CAP value for NAFLD/NASH patients, deduct 10 dB/m for diabetes patients,
and deduct/add 4.4 dB/m for each unit of BMI above/below 25 kg/m2 over the range of 20–
30 kg/m2.
- Taru MG, Neamti L, Taru V, Procopciuc LM, Procopet B, Lupsor-Platon M. How to
Identify Advanced Fibrosis in Adult Patients with Non-Alcoholic Fatty Liver Disease (NAFLD)
and Non-Alcoholic Steatohepatitis (NASH) Using Ultrasound Elastography-A Review of the
Literature and Proposed Multistep Approach. Diagnostics (Basel). 2023 Feb 19;13(4):788. doi:
10.3390/diagnostics13040788. PMID: 36832276; PMCID: PMC9955630.
-  Petroff D, Blank V, Newsome PN, et al. Assessment of hepatic steatosis by controlled
attenuation parameter using the M and XL probes: an individual patient data meta-analysis.
Lancet Gastroenterol Hepatol. 2021; 6:185–198.
Your references should be updated.
assistant