Evaluation of Ultrasound-Based Parameters for the Assessment of Hepatic Steatosis and Fibrosis in Hungarian Wilson’s Disease Patients

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Summary

This retrospective study evaluated the effectiveness of ultrasound-based tissue attenuation imaging (TAI), tissue scatter distribution imaging (TSI), and shear-wave elastography (SWE) in quantifying steatosis and fibrosis among 53 patients with Wilson’s disease. The results indicated that steatosis was generally mild, while liver stiffness demonstrated a positive correlation with calculated free copper levels and a negative correlation with serum ceruloplasmin concentrations. Quantitative ultrasound (QUS) may be utilized for monitoring therapeutic responses in patients with Wilson’s disease.

Comments

1. This team previously assessed QUS for liver steatosis in MAFLD and liver fibrosis in CHC. Now, they are thinking about applying their experience to evaluate steatosis and fibrosis by QUS in Wilson’s disease. However, since different causes can affect QUS differently, sharing these findings is valuable. For this reason, a gold standard method is necessary. They used MRI PDFF as the gold standard for steatosis but did not use a gold standard for assessing fibrosis.
2. QUS is suitable for a longitudinal follow-up study, where gold standards are less critical. A separate table is needed for the follow-up study, this manuscript reports only enrollment data.
3. Samsung RS85 Prestige was used in both this study and reference 25, but the terms UEFF and USFF were used differently. Please briefly describe this change.
4. Kindly provide the treatment duration at enrollment in Table 1. Additionally, can you explain why the USFF data cannot be shown separately for male and female categories in Table 1?
5. Figure 1 shows legends A and B, but not C or D. For Figure 1C, five measurements were taken from the same image, which may not reflect actual variability and could introduce bias.
6. Why isn't MRI PDFF included in Figure 3's correlation matrix? What do the different colored balls represent?
7. In Figure 5, what is the meaning of different color balls?
8. Figure 6 displays liver stiffness values from 2019 to 2024. Two panels are present, but no descriptions are provided.
9. In the second last paragraphs of the results section, the statement ‘Based on our calculations, the values indicating measured steatosis and fibrosis were mostly correlated with BMI, liver enzymes and triglyceride values’ is unclear. Steatosis and fibrosis are separate entities and should not be combined.
10. Discussion is redundant, please present your findings first, then reference other published experiences. Please delete those well-established knowledge that unrelated to your findings.

Author Response

We are pleased to resubmit our revised manuscript, entitled “Evaluation of Artificial Intelligence-Calculated Parameters for the Assessment of Hepatic Steatosis and Fibrosis in Hungarian Wilson’s disease patients” for consideration for publication in [Diagnostics].

We would like to thank the reviewers for their insightful and constructive feedback. In response to their comments, we have carefully revised the manuscript.

We believe these revisions have substantially improved the manuscript and address all concerns raised during the review process.

Thank you for your continued consideration of our work.

 

Sincerely,

Anikó Folhoffer MD, PhD

on behalf of all authors,

Dept of Internal Medicine and Oncology

Semmelweis University, Budapest

1083 Bp., Korányi S.2/A.

phone number:

+36-1-210278

+36 20 9949 678

e-mail:

folhoffer@gmail.com

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

1. The manuscript reports R² = −0.034. In standard regression analysis, the coefficient of determination R² is usually non-negative.
2. The manuscript describes p = 0.0762 as “nearly significant”. However, in conventional statistical interpretation, p > 0.05 is usually considered not significant, and the wording should be revised.
3. In Section 2.2, the authors use fibrosis cutoff values derived from VCTE studies, while this study uses 2D-SWE. The authors should explain the rationale and applicability of using these cutoff values for 2D-SWE.
4. The LS values reported in Table 1 and Figure 5 appear to be inconsistent. The authors should verify the data and explain this discrepancy.
5. Figure 6 has poor readability. It is difficult to understand what each curve represents, and the axis labels are unclear. The figure quality should be improved and the figure legend should provide clearer explanations.
6. In Table 1, the standard deviations of some variables (e.g., ALAT, GGT) are relatively large compared with the mean values. This seems unreasonable and should be explained by the authors.
7. The authors report data separately for male and female participants, but no statistical comparison between the two groups is presented. Please clarify whether sex differences were analyzed.
8. In Table 1, the unit for BMI should be kg/m², and in several places in the manuscript the “m²” is not formatted as a superscript. This should be corrected.
9. In line 236, the manuscript contains “MASLD/MASLD index”, where “MASLD” is repeated. This may be a typographical error.
10. The manuscript uses both r and R² when describing correlations. The notation should be used consistently.
11. In line 186, the authors state: “Only TAI values with R² > 0.6 were considered reliable.” Please provide a reference supporting this threshold.
12. Figures 1 and 2 do not appear to be referenced or described in the main text. Please cite them in the appropriate sections and briefly describe them.
13. The text in Discussion lines 324–326 is largely repeated from Introduction lines 90–92. This redundancy should be revised.

Author Response

We are pleased to resubmit our revised manuscript, entitled “Evaluation of Artificial Intelligence-Calculated Parameters for the Assessment of Hepatic Steatosis and Fibrosis in Hungarian Wilson’s disease patients” for consideration for publication in [Diagnostics].

We would like to thank the reviewers for their insightful and constructive feedback. In response to their comments, we have carefully revised the manuscript.

We believe these revisions have substantially improved the manuscript and address all concerns raised during the review process.

Thank you for your continued consideration of our work.

Sincerely,

Anikó Folhoffer MD, PhD

on behalf of all authors,

Dept of Internal Medicine and Oncology

Semmelweis University, Budapest

1083 Bp., Korányi S.2/A.

phone number:

+36-1-210278

+36 20 9949 678

e-mail:

folhoffer@gmail.com

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Comments on revised version

1. AI is not used in this manuscript; please remove any mention of AI from the title.
2. Without a gold standard, this study's results lack strong support.
3. For Figure 1, remove panels C and D, note in the legend that 2D elastography shows no fibrosis, and interpret steatosis grades A and B instead of stating steatosis >5%.
4. In Table 2, list steatosis and fibrosis parameters at enrollment and study end, and assess statistical significance.
5. Change the x-axis label in Figure 3.
6. For Figure 6, clarify your point as A and B appear almost identical.
7. The discussion should focus more on the study’s results.

Author Response

1. AI is not used in this manuscript; please remove any mention of AI from the title.

We thank the reviewer for this correction. We agree that the term "AI" was not appropriate for the specific methodology used in this study. We have revised the title to more accurately reflect the ultrasound-based techniques employed.

Revised Title: Evaluation of Ultrasound-based Parameters for the Assessment of Hepatic Steatosis and Fibrosis in Hungarian Wilson’s Disease Patients.

1. Without a gold standard, this study's results lack strong support. 

We acknowledge the reviewer's concern regarding the absence of a histological "gold standard" in this cohort. However, Wilson’s Disease is a rare metabolic disorder where liver biopsy is often clinically unnecessary for diagnosis or monitoring once the diagnosis is established. Performing invasive biopsies solely for the purpose of research validation would present significant ethical challenges.

To mitigate this, we utilized non-invasive ultrasound parameters that have been extensively validated against biopsy and MRI-PDFF/MRE in other chronic liver diseases (CLDs). While we acknowledge this as a limitation, our study provides valuable real-world data on the applicability of these validated tools specifically within the Hungarian WD population. We have added a comment to the Discussion section to further address this limitation and justify the use of validated surrogate markers.

1. For Figure 1, remove panels C and D, note in the legend that 2D elastography shows no fibrosis, and interpret steatosis grades A and B instead of stating steatosis >5%.

We removed panel C and D, and changed the legend.

1. In Table 2, list steatosis and fibrosis parameters at enrollment and study end, and assess statistical significance. 

We completed table 2 with fibrosis parameters. While concerning the steatotic parameters a significant technical limitation exists. Due to the multi-year duration of the study, different ultrasound platforms and software versions were utilized. Specifically, for steatosis  parameters (TAI, TSI, and USFF), baseline measurements are limited as the initial equipment lacked the capability to capture these metrics. 

1. Change the x-axis label in Figure 3.

On figure 3. correlation matrix was visualized, where the different colored dots represent the magnitude and direction of the correlations between the variables. The color bar at the right side of the plot represents the Pearson correlation coefficient.

As suggested by the Reviewer, we have updated the X-axis labels in Figure 3 to include the full names of the variables and their respective units (e.g., Liver stiffness (kPa), Serum copper (µmol/L), serum coeuloplasmin (g/l)."

1. For Figure 6, clarify your point as A and B appear almost identical.

We are appreciate for your comment. We agree with the reviewer that panels A and B were redundant. Panel B was originally intended to highlight a trend using a regression line; however, we acknowledge that it did not provide additional significant information beyond what was already visible in Panel A. We have therefore removed the duplicate panel and kept only the most representative image. Figure 6 has been updated accordingly in the revised manuscript.

1. The discussion should focus more on the study’s results.

We have refocused the Discussion section on our primary study results and original data, significantly reducing the general literature overview to prioritize our findings.

Reviewer 2 Report

Comments and Suggestions for Authors

The author has answered all my questions. I have no further comments.

Author Response

We are appreciate for your review. 

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

The author addressed most of my comments. No gold standard is still a concern.