Title: Association between neutrophil-to-high-density lipoprotein cholesterol ratio and
metabolic dysfunction-associated steatotic liver disease and liver fibrosis in the US population:
a nationally representative cross-sectional study using NHANES data from 2017 to 2020
Version: 2 Date: 26 Jul 2024
Reviewer's report:
Summary:
This is an analysis of NHANES data looking at the association between neutrophil to HDL ratio
(NHR) and MASLD/fibrosis. The authors found a statistically significant positive association
between NHR and MASLD and a U-shaped relationship between NHR and fibrosis. The
association remained significant even after adjustment for covariates.
This manuscript needs substantial editing for language, clarity, and typos.
Comments:
• Editing the English for language and clarity is needed for the entire manuscript.
• Introduction: would avoid the terminology “unhealthy lifestyles” as it is stigmatizing
• Methods: what is the primary outcome? MASLD? MASLD + fibrosis? This should be clearly
stated in the Methods.
• Methods (data and sample source): editing for clarity needed. What does “We excluded the data
lack of NHR” mean? You excluded participants for whom NHR was unable to be calculated?
• Methods (definition of MASLD): probably a typo, but the numbers 1 through 5 are listed twice.
Would proofread carefully.
• Methods: “Liver fibrosis” threshold of 8.2 kPa should be described as “clinically significant
fibrosis” as patients with LSM under this could have fibrosis too.
• Methods (calculation of NHR): “Every blood sample was taken with the stomach empty”
should be revised to “blood samples were obtained after an X hour fast.” You do not need to
say “NHR is the independent variable”—that is clear from the Methods. You do need to specify
your outcomes as above.
• Methods (covariates): would describe PIR categories when you introduce PIR.
• Methods: are you using sex at birth or gender identity? Would change terminology to “sex”
if using sex at birth.
• Table 2: title should read “MASLD” not “NAFLD”
• Table 3: title should read “MASLD” not “MSALD”
• Table 5: title should read “MASLD” not “MSALD”
• Results (subgroup analysis): what is “hepatic fibers”?
• Discussion: would emphasize that one advantage of NHR is the fact that the labs needed to
calculate it are routinely collected in patients with and without liver disease
• Discussion: would expand on the idea that the cross-sectional design is a limitation.  I agree,
mostly for the reason that where NHR would be helpful is in predicting future development of
MASLD. If we are wondering if a patient currently has MASLD, we would do a Fibroscan or
imaging instead of relying on a non-invasive marker that is less accurate. But, if NHR in patients
without MASLD was associated with future development of MASLD, then NHR could have a
role in clinical practice (for example, patients with elevated NHR could be put on a screening
pathway for MASLD).
Title: Association between neutrophil-to-high-density lipoprotein cholesterol ratio and
metabolic dysfunction-associated steatotic liver disease and liver fibrosis in the US population:
a nationally representative cross-sectional study using NHANES data from 2017 to 2020
Version: 2 Date: 26 Jul 2024
Reviewer's report:
Summary:
This is an analysis of NHANES data looking at the association between neutrophil to HDL ratio
(NHR) and MASLD/fibrosis. The authors found a statistically significant positive association
between NHR and MASLD and a U-shaped relationship between NHR and fibrosis. The
association remained significant even after adjustment for covariates.
This manuscript needs substantial editing for language, clarity, and typos.
Comments:
• Editing the English for language and clarity is needed for the entire manuscript.
• Introduction: would avoid the terminology “unhealthy lifestyles” as it is stigmatizing
• Methods: what is the primary outcome? MASLD? MASLD + fibrosis? This should be clearly
stated in the Methods.
• Methods (data and sample source): editing for clarity needed. What does “We excluded the data
lack of NHR” mean? You excluded participants for whom NHR was unable to be calculated?
• Methods (definition of MASLD): probably a typo, but the numbers 1 through 5 are listed twice.
Would proofread carefully.
• Methods: “Liver fibrosis” threshold of 8.2 kPa should be described as “clinically significant
fibrosis” as patients with LSM under this could have fibrosis too.
• Methods (calculation of NHR): “Every blood sample was taken with the stomach empty”
should be revised to “blood samples were obtained after an X hour fast.” You do not need to
say “NHR is the independent variable”—that is clear from the Methods. You do need to specify
your outcomes as above.
• Methods (covariates): would describe PIR categories when you introduce PIR.
• Methods: are you using sex at birth or gender identity? Would change terminology to “sex”
if using sex at birth.
• Table 2: title should read “MASLD” not “NAFLD”
• Table 3: title should read “MASLD” not “MSALD”
• Table 5: title should read “MASLD” not “MSALD”
• Results (subgroup analysis): what is “hepatic fibers”?
• Discussion: would emphasize that one advantage of NHR is the fact that the labs needed to
calculate it are routinely collected in patients with and without liver disease
• Discussion: would expand on the idea that the cross-sectional design is a limitation.  I agree,
mostly for the reason that where NHR would be helpful is in predicting future development of
MASLD. If we are wondering if a patient currently has MASLD, we would do a Fibroscan or
imaging instead of relying on a non-invasive marker that is less accurate. But, if NHR in patients
without MASLD was associated with future development of MASLD, then NHR could have a
role in clinical practice (for example, patients with elevated NHR could be put on a screening
pathway for MASLD).
Please review this paper.
user
Title: Association between neutrophil-to-high-density lipoprotein cholesterol ratio and
metabolic dysfunction-associated steatotic liver disease and liver fibrosis in the US population:
a nationally representative cross-sectional study using NHANES data from 2017 to 2020
Version: 2 Date: 26 Jul 2024
Reviewer's report:
Summary:
This is an analysis of NHANES data looking at the association between neutrophil to HDL ratio
(NHR) and MASLD/fibrosis. The authors found a statistically significant positive association
between NHR and MASLD and a U-shaped relationship between NHR and fibrosis. The
association remained significant even after adjustment for covariates.
This manuscript needs substantial editing for language, clarity, and typos.
Comments:
• Editing the English for language and clarity is needed for the entire manuscript.
• Introduction: would avoid the terminology “unhealthy lifestyles” as it is stigmatizing
• Methods: what is the primary outcome? MASLD? MASLD + fibrosis? This should be clearly
stated in the Methods.
• Methods (data and sample source): editing for clarity needed. What does “We excluded the data
lack of NHR” mean? You excluded participants for whom NHR was unable to be calculated?
• Methods (definition of MASLD): probably a typo, but the numbers 1 through 5 are listed twice.
Would proofread carefully.
• Methods: “Liver fibrosis” threshold of 8.2 kPa should be described as “clinically significant
fibrosis” as patients with LSM under this could have fibrosis too.
• Methods (calculation of NHR): “Every blood sample was taken with the stomach empty”
should be revised to “blood samples were obtained after an X hour fast.” You do not need to
say “NHR is the independent variable”—that is clear from the Methods. You do need to specify
your outcomes as above.
• Methods (covariates): would describe PIR categories when you introduce PIR.
• Methods: are you using sex at birth or gender identity? Would change terminology to “sex”
if using sex at birth.
• Table 2: title should read “MASLD” not “NAFLD”
• Table 3: title should read “MASLD” not “MSALD”
• Table 5: title should read “MASLD” not “MSALD”
• Results (subgroup analysis): what is “hepatic fibers”?
• Discussion: would emphasize that one advantage of NHR is the fact that the labs needed to
calculate it are routinely collected in patients with and without liver disease
• Discussion: would expand on the idea that the cross-sectional design is a limitation.  I agree,
mostly for the reason that where NHR would be helpful is in predicting future development of
MASLD. If we are wondering if a patient currently has MASLD, we would do a Fibroscan or
imaging instead of relying on a non-invasive marker that is less accurate. But, if NHR in patients
without MASLD was associated with future development of MASLD, then NHR could have a
role in clinical practice (for example, patients with elevated NHR could be put on a screening
pathway for MASLD).
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