Reviewer’s report
Title: 
CT-based Hounsfield unit values reflect the degree of steatohepatitis in
patients with low-grade fatty liver disease
Version: 
0 
Date: 
02 Oct 2022
Reviewer's report:
I read with interest the paper "Is CT-based Hounsfield unit values and hepatic
steatosis index really useless in lowgrade fatty liver disease?" by 
Kim et al. 
I agree with the authors that diagnosing NAFLD non-invasively is challenging
and therefore the paper is of interest. The paper is well written and the analysis
are well considered wisely I am not quite sure on how clinically important these
findings are!
All guidelines published recently on (AASLD; EASL; DGVS) are based on the
risk stratification being at risk of developing a significant liver disease as it is of
major importance to identify patients at risk for NASH that is considered a
precancerous condition. As shown for bland steatosis, liver cell steatosis alone is
not an independent risk factor for progression to liver fibrosis and is therefore
unsuitable as a surrogate marker for the inflammatory activity of NAFLD,
therefore the authors may have used the NAS score instead (Kleiner DE, Brunt
EM, Van Natta M, et al. Design and validation of a histological scoring system
for nonalcoholic fatty liver disease. Hepatology 2005;41:1313-21). . As,
evidence of liver cell steatosis typifies the disease (steato-), while inflammatory
activity is characterized by the extent of lobular inflammation and hepatocellular
ballooning (Petrick JL, Thistle JE, Zeleniuch-Jacquotte A, et al. Body Mass
Index, Diabetes and Intrahepatic Cholangiocarcinoma Risk: The Liver Cancer
Pooling Project and Meta-analysis. Am J Gastroenterol 2018;113:1494-1505).
NAFLD is diagosed mostly in patient with metabolic Syndrome therefore the
authors must give us clinical inside of the number of patients who fulfilled the
criteria for MS and give us information if those with MS fulfil risk for
progression to fibrosis and cirrhosis. It is well known that CT has a good tool for
diagnosing NAFLD (Iwasaki M, Takada Y, Hayashi M, et al. Noninvasive
evaluation of graft steatosis in living donor liver transplantation. Transplantation
2004;78:1501-5.), but because of its radiation exposure, CT should not be used
as a screening method for the detection of NAFLD. Moreover 
cardiovascular and
non-hepatic morbidity and mortality are more common in non-cirrhotic NAFLD
patients, while complications of advanced liver disease determine the further
prognosis in cases of established liver cirrhosis it is essential to identify patients
at risk for fibrosis and cirrhosis. 
Publons Reviewer Recognition
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find the details of processing in Publons’ privacy policy
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Yes
Declaration of competing interests
Please complete a declaration of competing
interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
none
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Reviewer’s report
Title: 
CT-based Hounsfield unit values reflect the degree of steatohepatitis in
patients with low-grade fatty liver disease
Version: 
0 
Date: 
02 Oct 2022
Reviewer's report:
I read with interest the paper "Is CT-based Hounsfield unit values and hepatic
steatosis index really useless in lowgrade fatty liver disease?" by 
Kim et al. 
I agree with the authors that diagnosing NAFLD non-invasively is challenging
and therefore the paper is of interest. The paper is well written and the analysis
are well considered wisely I am not quite sure on how clinically important these
findings are!
All guidelines published recently on (AASLD; EASL; DGVS) are based on the
risk stratification being at risk of developing a significant liver disease as it is of
major importance to identify patients at risk for NASH that is considered a
precancerous condition. As shown for bland steatosis, liver cell steatosis alone is
not an independent risk factor for progression to liver fibrosis and is therefore
unsuitable as a surrogate marker for the inflammatory activity of NAFLD,
therefore the authors may have used the NAS score instead (Kleiner DE, Brunt
EM, Van Natta M, et al. Design and validation of a histological scoring system
for nonalcoholic fatty liver disease. Hepatology 2005;41:1313-21). . As,
evidence of liver cell steatosis typifies the disease (steato-), while inflammatory
activity is characterized by the extent of lobular inflammation and hepatocellular
ballooning (Petrick JL, Thistle JE, Zeleniuch-Jacquotte A, et al. Body Mass
Index, Diabetes and Intrahepatic Cholangiocarcinoma Risk: The Liver Cancer
Pooling Project and Meta-analysis. Am J Gastroenterol 2018;113:1494-1505).
NAFLD is diagosed mostly in patient with metabolic Syndrome therefore the
authors must give us clinical inside of the number of patients who fulfilled the
criteria for MS and give us information if those with MS fulfil risk for
progression to fibrosis and cirrhosis. It is well known that CT has a good tool for
diagnosing NAFLD (Iwasaki M, Takada Y, Hayashi M, et al. Noninvasive
evaluation of graft steatosis in living donor liver transplantation. Transplantation
2004;78:1501-5.), but because of its radiation exposure, CT should not be used
as a screening method for the detection of NAFLD. Moreover 
cardiovascular and
non-hepatic morbidity and mortality are more common in non-cirrhotic NAFLD
patients, while complications of advanced liver disease determine the further
prognosis in cases of established liver cirrhosis it is essential to identify patients
at risk for fibrosis and cirrhosis. 
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing
interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
none
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
CT-based Hounsfield unit values reflect the degree of steatohepatitis in
patients with low-grade fatty liver disease
Version: 
0 
Date: 
02 Oct 2022
Reviewer's report:
I read with interest the paper "Is CT-based Hounsfield unit values and hepatic
steatosis index really useless in lowgrade fatty liver disease?" by 
Kim et al. 
I agree with the authors that diagnosing NAFLD non-invasively is challenging
and therefore the paper is of interest. The paper is well written and the analysis
are well considered wisely I am not quite sure on how clinically important these
findings are!
All guidelines published recently on (AASLD; EASL; DGVS) are based on the
risk stratification being at risk of developing a significant liver disease as it is of
major importance to identify patients at risk for NASH that is considered a
precancerous condition. As shown for bland steatosis, liver cell steatosis alone is
not an independent risk factor for progression to liver fibrosis and is therefore
unsuitable as a surrogate marker for the inflammatory activity of NAFLD,
therefore the authors may have used the NAS score instead (Kleiner DE, Brunt
EM, Van Natta M, et al. Design and validation of a histological scoring system
for nonalcoholic fatty liver disease. Hepatology 2005;41:1313-21). . As,
evidence of liver cell steatosis typifies the disease (steato-), while inflammatory
activity is characterized by the extent of lobular inflammation and hepatocellular
ballooning (Petrick JL, Thistle JE, Zeleniuch-Jacquotte A, et al. Body Mass
Index, Diabetes and Intrahepatic Cholangiocarcinoma Risk: The Liver Cancer
Pooling Project and Meta-analysis. Am J Gastroenterol 2018;113:1494-1505).
NAFLD is diagosed mostly in patient with metabolic Syndrome therefore the
authors must give us clinical inside of the number of patients who fulfilled the
criteria for MS and give us information if those with MS fulfil risk for
progression to fibrosis and cirrhosis. It is well known that CT has a good tool for
diagnosing NAFLD (Iwasaki M, Takada Y, Hayashi M, et al. Noninvasive
evaluation of graft steatosis in living donor liver transplantation. Transplantation
2004;78:1501-5.), but because of its radiation exposure, CT should not be used
as a screening method for the detection of NAFLD. Moreover 
cardiovascular and
non-hepatic morbidity and mortality are more common in non-cirrhotic NAFLD
patients, while complications of advanced liver disease determine the further
prognosis in cases of established liver cirrhosis it is essential to identify patients
at risk for fibrosis and cirrhosis. 
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing
interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
none
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
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