Title: The Prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)-
Related Advanced Fibrosis and Cirrhosis in the United States Population Utilizing AGILE 3+
and AGILE 4 Scores: Analysis of the NHANES 2017-2018 Cycle
Version: 0 Date: 20 Oct 2023
Reviewer's report:
The authors used the NHANES 2017-2018 survey to determine the prevalence of NASH-related
advanced fibrosis and cirrhosis in the general US population. They fou  that the prevalence of
AF and cirrhosis in the general prevalence was 8.1% and 1.1% respectively.
This is an important question to answer however there is a need to present more information
to clarify the percentages and the resulting absolute numbers of Americans living with NASH-
related AF and cirrhosis. The authors report that "The overall prevalence of AF due to NAFLD
was 8.1% (6.2-10.6) corresponding to 4.5 million Americans. ". This is somewhat confusing as
8.1% of Americans is not 4.5M. Is the 8.1% the prevalence of AF due to NAFLD in the general
US population or is this the prevalence of AF in the NAFLD population in this NHANES survey
and using this and back calculations using survey weights, the absolute number thus came about?
This same question applies to the statement "The overall prevalence of NASH cirrhosis was 1.1
% (95% CI: 0.5-2.3) corresponding to 610,000 Americans."
This is further confused by the statement "We further stratified based on steatosis (CAP # 248
dB/m) to identify NAFLD. Our final sample was 1244 participants. Obesity was defined as a
Body Mass Index (BMI) of 30 kg/m2 or more." So the 1244 was the final denominator? And
they were not all NAFLD (CAP >248)? What was the prevalence of NAFLD then?
Looking at Figure 1, would it not be better to have excluded only the participants aged <18,
did not have transient elastography and Agile 3+/4+ calculation and used the resulting sample
as the denominator  (general population) for the prevalence of NAFLD using CAP>248 and
excluding the ones with HBV, HCV, and alcohol.? Then applying Agile 3+/4+ then gives both
the prevalence of NAFLD and fibrotic NAFLD in the general US population. Perhaps with this
analysis, the authors can also look at the predictors of NAFLD and fibrotic NAFLD in the US
population.
A more detailed description of this particular iteration of NHANES will also be helpful. We
all the patients offered VCTE? How many accepted and had successful VCTE?  What was the
proportion of missing data? There seems to be a very large number who had missing data and
should be mentioned as a limitation.
Title: The Prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)-
Related Advanced Fibrosis and Cirrhosis in the United States Population Utilizing AGILE 3+
and AGILE 4 Scores: Analysis of the NHANES 2017-2018 Cycle
Version: 0 Date: 20 Oct 2023
Reviewer's report:
The authors used the NHANES 2017-2018 survey to determine the prevalence of NASH-related
advanced fibrosis and cirrhosis in the general US population. They fou  that the prevalence of
AF and cirrhosis in the general prevalence was 8.1% and 1.1% respectively.
This is an important question to answer however there is a need to present more information
to clarify the percentages and the resulting absolute numbers of Americans living with NASH-
related AF and cirrhosis. The authors report that "The overall prevalence of AF due to NAFLD
was 8.1% (6.2-10.6) corresponding to 4.5 million Americans. ". This is somewhat confusing as
8.1% of Americans is not 4.5M. Is the 8.1% the prevalence of AF due to NAFLD in the general
US population or is this the prevalence of AF in the NAFLD population in this NHANES survey
and using this and back calculations using survey weights, the absolute number thus came about?
This same question applies to the statement "The overall prevalence of NASH cirrhosis was 1.1
% (95% CI: 0.5-2.3) corresponding to 610,000 Americans."
This is further confused by the statement "We further stratified based on steatosis (CAP # 248
dB/m) to identify NAFLD. Our final sample was 1244 participants. Obesity was defined as a
Body Mass Index (BMI) of 30 kg/m2 or more." So the 1244 was the final denominator? And
they were not all NAFLD (CAP >248)? What was the prevalence of NAFLD then?
Looking at Figure 1, would it not be better to have excluded only the participants aged <18,
did not have transient elastography and Agile 3+/4+ calculation and used the resulting sample
as the denominator  (general population) for the prevalence of NAFLD using CAP>248 and
excluding the ones with HBV, HCV, and alcohol.? Then applying Agile 3+/4+ then gives both
the prevalence of NAFLD and fibrotic NAFLD in the general US population. Perhaps with this
analysis, the authors can also look at the predictors of NAFLD and fibrotic NAFLD in the US
population.
A more detailed description of this particular iteration of NHANES will also be helpful. We
all the patients offered VCTE? How many accepted and had successful VCTE?  What was the
proportion of missing data? There seems to be a very large number who had missing data and
should be mentioned as a limitation.
Please review this paper.
user
Title: The Prevalence of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)-
Related Advanced Fibrosis and Cirrhosis in the United States Population Utilizing AGILE 3+
and AGILE 4 Scores: Analysis of the NHANES 2017-2018 Cycle
Version: 0 Date: 20 Oct 2023
Reviewer's report:
The authors used the NHANES 2017-2018 survey to determine the prevalence of NASH-related
advanced fibrosis and cirrhosis in the general US population. They fou  that the prevalence of
AF and cirrhosis in the general prevalence was 8.1% and 1.1% respectively.
This is an important question to answer however there is a need to present more information
to clarify the percentages and the resulting absolute numbers of Americans living with NASH-
related AF and cirrhosis. The authors report that "The overall prevalence of AF due to NAFLD
was 8.1% (6.2-10.6) corresponding to 4.5 million Americans. ". This is somewhat confusing as
8.1% of Americans is not 4.5M. Is the 8.1% the prevalence of AF due to NAFLD in the general
US population or is this the prevalence of AF in the NAFLD population in this NHANES survey
and using this and back calculations using survey weights, the absolute number thus came about?
This same question applies to the statement "The overall prevalence of NASH cirrhosis was 1.1
% (95% CI: 0.5-2.3) corresponding to 610,000 Americans."
This is further confused by the statement "We further stratified based on steatosis (CAP # 248
dB/m) to identify NAFLD. Our final sample was 1244 participants. Obesity was defined as a
Body Mass Index (BMI) of 30 kg/m2 or more." So the 1244 was the final denominator? And
they were not all NAFLD (CAP >248)? What was the prevalence of NAFLD then?
Looking at Figure 1, would it not be better to have excluded only the participants aged <18,
did not have transient elastography and Agile 3+/4+ calculation and used the resulting sample
as the denominator  (general population) for the prevalence of NAFLD using CAP>248 and
excluding the ones with HBV, HCV, and alcohol.? Then applying Agile 3+/4+ then gives both
the prevalence of NAFLD and fibrotic NAFLD in the general US population. Perhaps with this
analysis, the authors can also look at the predictors of NAFLD and fibrotic NAFLD in the US
population.
A more detailed description of this particular iteration of NHANES will also be helpful. We
all the patients offered VCTE? How many accepted and had successful VCTE?  What was the
proportion of missing data? There seems to be a very large number who had missing data and
should be mentioned as a limitation.
assistant