Title: Metabolic Dysfunction-Associated Steatotic Liver Disease, Metabolic Alcohol-Related
Liver Disease, and Incident Dementia: a nationwide cohort study MASLD, MetALD, and
dementia risk
Version: 2 Date: 21 Feb 2025
Reviewer's report:
I read with interest this carefully conducted study on MASLD and MetALD and the risk
for dementia during  a follow-up of approximately 10 years. The study evaluates if there
is an increased risk for Alzheimer´s disease and/ or vascular dementia or both associated
with metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic alcohol-
associated liver disease (MetALD). The statistical methods used to study these associations are
sophisticated and robust  since they include the traditional Cox proportional Hazards model as
well as the  Fine-Gray competing risk model . Covariates are taken into account by inverse
probability of treatment weighting .
The manuscript is clearly written and relevant previous studies are cited appropriately. The
Tables and the figures are informative and all the relevant data needed to interpret the validity
of  the analyses and the results  is presented in the supplement. Sensitivity analyses are included
and especially adding analyses with  increasing latent periods (excluding individuals who were
diagnosed with dementia 1, 2 or 3 years after the initial assessment of MASLD/MetALD)
contributes to the results, since the association between MetALD and AD was reversed after
the 3-years latent period.
I have only very minor comments on the manuscript.
1. Please define the abbreviation FLI when it its first mentioned for readers not familiar with it.
2. In the introduction you point out that recent studies (The Rotterdam study and a study on
the UK biobank data)  found no association between NAFLD and dementia. It would be useful
to try to hypothesize why these studies yielded different results when compared to the present
study. Different statistical methods/ smaller study populations/ European vs. Asian cohort?
Title: Metabolic Dysfunction-Associated Steatotic Liver Disease, Metabolic Alcohol-Related
Liver Disease, and Incident Dementia: a nationwide cohort study MASLD, MetALD, and
dementia risk
Version: 2 Date: 21 Feb 2025
Reviewer's report:
I read with interest this carefully conducted study on MASLD and MetALD and the risk
for dementia during  a follow-up of approximately 10 years. The study evaluates if there
is an increased risk for Alzheimer´s disease and/ or vascular dementia or both associated
with metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic alcohol-
associated liver disease (MetALD). The statistical methods used to study these associations are
sophisticated and robust  since they include the traditional Cox proportional Hazards model as
well as the  Fine-Gray competing risk model . Covariates are taken into account by inverse
probability of treatment weighting .
The manuscript is clearly written and relevant previous studies are cited appropriately. The
Tables and the figures are informative and all the relevant data needed to interpret the validity
of  the analyses and the results  is presented in the supplement. Sensitivity analyses are included
and especially adding analyses with  increasing latent periods (excluding individuals who were
diagnosed with dementia 1, 2 or 3 years after the initial assessment of MASLD/MetALD)
contributes to the results, since the association between MetALD and AD was reversed after
the 3-years latent period.
I have only very minor comments on the manuscript.
1. Please define the abbreviation FLI when it its first mentioned for readers not familiar with it.
2. In the introduction you point out that recent studies (The Rotterdam study and a study on
the UK biobank data)  found no association between NAFLD and dementia. It would be useful
to try to hypothesize why these studies yielded different results when compared to the present
study. Different statistical methods/ smaller study populations/ European vs. Asian cohort?
Please review this paper.
user
Title: Metabolic Dysfunction-Associated Steatotic Liver Disease, Metabolic Alcohol-Related
Liver Disease, and Incident Dementia: a nationwide cohort study MASLD, MetALD, and
dementia risk
Version: 2 Date: 21 Feb 2025
Reviewer's report:
I read with interest this carefully conducted study on MASLD and MetALD and the risk
for dementia during  a follow-up of approximately 10 years. The study evaluates if there
is an increased risk for Alzheimer´s disease and/ or vascular dementia or both associated
with metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic alcohol-
associated liver disease (MetALD). The statistical methods used to study these associations are
sophisticated and robust  since they include the traditional Cox proportional Hazards model as
well as the  Fine-Gray competing risk model . Covariates are taken into account by inverse
probability of treatment weighting .
The manuscript is clearly written and relevant previous studies are cited appropriately. The
Tables and the figures are informative and all the relevant data needed to interpret the validity
of  the analyses and the results  is presented in the supplement. Sensitivity analyses are included
and especially adding analyses with  increasing latent periods (excluding individuals who were
diagnosed with dementia 1, 2 or 3 years after the initial assessment of MASLD/MetALD)
contributes to the results, since the association between MetALD and AD was reversed after
the 3-years latent period.
I have only very minor comments on the manuscript.
1. Please define the abbreviation FLI when it its first mentioned for readers not familiar with it.
2. In the introduction you point out that recent studies (The Rotterdam study and a study on
the UK biobank data)  found no association between NAFLD and dementia. It would be useful
to try to hypothesize why these studies yielded different results when compared to the present
study. Different statistical methods/ smaller study populations/ European vs. Asian cohort?
assistant