From “MAFLD” to “MASLD”: Was This Revolution Worth It? A Head-to-Head Comparison of MAFLD and MASLD Criteria in Estimating Liver Disease Progression and Cardiovascular Risk in Real Life

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have conducted a well-designed study comparing MAFLD and MASLD diagnostic criteria, particularly across lean and non-lean subgroups. The analysis of disease progression and cardiovascular outcomes provides fresh insights based on a large clinical dataset. The manuscript is of interest, but a few clarifications and additional analyses would further improve its impact.

Specific Comments:

1. For the non-lean group, could the authors explore whether gender differences affect the prediction of advanced fibrosis, HCC, or cardiovascular events?

2. In lean MAFLD, both exercise and Mediterranean diet compliance were associated with fibrosis progression over three years. This finding seems unexpected—could the authors discuss possible explanations or mechanisms in the Discussion section?

3. Given the relatively small number of lean MAFLD/MASLD patients, validation using an additional cohort, if available, would make the conclusions more convincing.

Author Response

Specific Comments:

1. For the non-lean group, could the authors explore whether gender differences affect the prediction of advanced fibrosis, HCC, or cardiovascular events?

Reply: We thank the Reviewer for this pertinent and precious observation. In response, we have conducted additional subgroup analyses to explore potential gender-related differences in the prediction of advanced fibrosis (AF), hepatocellular carcinoma (HCC), and cardiovascular events (ACEs) within the non-lean (NL) cohort. While preliminary trends suggested possible sex-specific variations in risk profiles—particularly regarding cardiovascular outcomes—these did not reach statistical significance in our dataset. Nonetheless, we acknowledge that gender-related metabolic and hormonal factors may influence disease progression and outcome prediction. We have accordingly revised (and properly referenced) the discussion to reflect these considerations and propose that future studies with larger sample sizes and sex-stratified designs are warranted to more definitively assess gender-specific risk modulation in NL individuals.

 

2. In lean MAFLD, both exercise and Mediterranean diet compliance were associated with fibrosis progression over three years. This finding seems unexpected—could the authors discuss possible explanations or mechanisms in the Discussion section?

Reply: We sincerely thank the Reviewer for this relevant notification. As previously reported in the main text and in table 1 (in the current version of the revised manuscript, table 2), […] “in Lean MAFLD, T2DM (p<0.0001), dyslipidemia (p = 0.002), physical exercise (p = 0.03), Mediterranean Diet compliance (p = 0.02) HOMA-IR, and hs-CRP (both p < 0.0001) were evidenced as variables significantly associated with 3-year AF progression (Table 2). The multivariate analysis revealed T2DM (p = 0.001), HOMA-IR (p = 0.02), and hs-CRP (p = 0.03) as the exclusive variables significantly impacting the outcome in these individuals, independently of sex, age, BMI, diabetes, steatosis, and fibrosis severity (Table 2). […]”. Anyway, while T2DM, dyslipidemia, HOMA-IR, and hs-CRP present a positive (> 1) Hazard Ratio - and are thus variables of risk for AF progression, physical exercise and Mediterranean Diet compliance should be intended as “protective” variables (HR: 0.349; HR: 0.491) for this outcome, thus representing expected results.

Considering this, aiming to increase the readability and the level of clarity in the interpretability of the results, the sentence has been rephrased and we have added the Hazard Ratios also in the main text.

 

3. Given the relatively small number of lean MAFLD/MASLD patients, validation using an additional cohort, if available, would make the conclusions more convincing.

Reply: We sincerely thank the reviewer for this relevant comment and we completely agree with these precious suggestions. Unfortunately, an additional cohort of Lean is not available in terms of follow-up data for the assessed outcomes. In this sense, in the present research, the relatively limited number of considered L-individuals represents a faithful portrait of the rarity of this condition in this setting of subjects, as clinicians meet in their routine clinical practice, simultaneously representing the consequence of a “rigid” identification-extraction-selection process which was performed to “clean” the data and observe the pure “effects” of MAFLD and MASLD application criteria on the study population. Therefore, as reported in the revised discussion section, the results of this pioneering presented research should be interpreted with caution, representing emerging findings opening to further larger investigations and validations.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting and timely clinical study that addresses an important question regarding the clinical impact of the newly proposed MASLD definition compared with MAFLD. The authors analyzed a large hospital-based cohort and evaluated short-term (3-year) risks of advanced fibrosis (AF) progression, hepatocellular carcinoma (HCC) occurrence, and acute cardiovascular events (ACEs). The study is methodologically detailed and statistically comprehensive, and the findings—particularly that MAFLD better predicts AF progression in lean patients—are relevant to current discussions on metabolic liver disease nomenclature.

However, several aspects need clarification, improvement, and contextualization.

1. The topic is important given the global transition from MAFLD to MASLD terminology, but the manuscript should emphasize its added value more clearly. The authors should state explicitly how their European cohort and short-term outcomes provide new insights beyond previous mortality-based studies.
2. The study relies on retrospective electronic medical records. The selection bias should be more clearly discussed—e.g., whether the requirement for 3-year follow-up excluded patients with more severe disease or those lost to follow-up. Please clarify the representativeness of the lean subgroup (n=134; only 27 in lean-MAFLD). Such small numbers limit statistical power. Confidence intervals or effect sizes should be interpreted with caution.
3. The definitions of MASLD and MAFLD are well described. However, it would be helpful to include a summary table comparing both criteria side by side for clarity.
4. The main finding—that MAFLD performs better in lean patients—should be discussed more mechanistically. Why might HOMA-IR and hs-CRP capture fibrosis risk more accurately than MASLD’s simplified cardiometabolic factors?
5. The absence of difference in HCC or ACE incidence between definitions is an important negative finding. The authors should discuss whether the short follow-up (3 years) and limited events may have obscured real differences.
6. The authors suggest revising MASLD criteria to reintroduce hs-CRP and HOMA-IR—this is provocative but should be framed as a hypothesis for future validation, not a definitive recommendation.

Author Response

 

1. The topic is important given the global transition from MAFLD to MASLD terminology, but the manuscript should emphasize its added value more clearly. The authors should state explicitly how their European cohort and short-term outcomes provide new insights beyond previous mortality-based studies.

Reply:  We appreciate the Reviewer’s insightful observation regarding the relevance of our study within the evolving framework of MASLD terminology. In response, we have revised the manuscript to more explicitly highlight its added value. Specifically, in the introduction and in the discussion section, we have properly emphasized that, to the best of our knowledge, this study is the first to present a direct, comparative evaluation of the diagnostic criteria for MAFLD and MASLD, demonstrating no statistically significant differences in their ability to predict the investigated outcomes. However, a noteworthy exception emerged in the subgroup of non-obese individuals, where MAFLD exhibited a modest yet clinically relevant superiority in forecasting the 3-year risk of AF progression.

We sincerely thank the Reviewer for this valuable suggestion, and we are sure that, thanks to this revision, the quality, as well as the level of impact of our paper, has been critically increased. 

 

2. The study relies on retrospective electronic medical records. The selection bias should be more clearly discussed—e.g., whether the requirement for 3-year follow-up excluded patients with more severe disease or those lost to follow-up. Please clarify the representativeness of the lean subgroup (n=134; only 27 in lean-MAFLD). Such small numbers limit statistical power. Confidence intervals or effect sizes should be interpreted with caution.

Reply: We sincerely thank the reviewer for this relevant comment and we completely agree with these precious suggestions. Considering these, in the resubmitted version of our manuscript, all these critical points and limitations have been properly discussed.  

Concerning the fact that study relies on electronic medical records, retrospective nature of the recruitment implying relative potential biases has been clearly reported. Anyway, despite this basic limitation, all information and recorded events, including HCC occurrence, was constantly supported by genuine clinical documentation, and the robustness of the emerging findings was consolidated by properly excluding - in the relative selection process- patients presenting with ACLD, subjects which were not HCC or ACEs naïve, as well as individuals which were lost to follow-up. Contrariwise, patients presenting with baseline AF (LSM: > F3) and severe steatosis (CAP: S3) were not excluded to both propose a faithful portrait of real-life clinical scenarios and evaluate the impact of baseline condition and of the variations (D: baseline -T0- vs last visit- T1-) in LTE (both in LSM and CAP: D LSM and D CAP) on the assessed outcomes.

Moreover, as properly reported in the revised discussion section in illustrating the study limitations, the authors know that the present research represents a single-center experience with limited observations. However, as described in the dedicated sub-paragraph “2.4 Statistical Analysis”, the sample size estimation was adequately performed based on the primary end-point (i.e., to highlight a statistically significant difference – of at least 20% of patients progressing to advanced fibrosis progression- in the two main study groups: “NL-SLD pure MASLD” vs “NL-SLD pure MAFLD”). Therefore, as reported, at the end of the identification-extraction-selection process, consistently with sample size estimation, an adequate number of NL-SLD individuals was enrolled, consistently with the primary outcome.

Concerning the Lean (L) patients, the limited number of considered individuals represents a faithful portrait of the rarity of this condition in this setting of subjects, as clinicians meet in their routine clinical practice, simultaneously representing the consequence of a “rigid” identification-extraction-selection process which was performed to “clean” the data and observe the pure “effects” of MAFLD and MASLD application criteria on the study population. Anyway, in line with this, we would remark on the nature of observations relative to L patients: as specified in the resubmitted modified version of our manuscript, the findings in this group were obtained by performing a sub-analysis and, consequently, all the observations must be considered as secondary outcomes (in contrast to what performed and observed in the NL-SLD), and should be interpreted with caution, representing emerging results opening to further larger investigations and validations.

3. The definitions of MASLD and MAFLD are well described. However, it would be helpful to include a summary table comparing both criteria side by side for clarity.

Reply: We thank the Reviewer for this constructive recommendation. As suggested, we have added a summary table that presents a side-by-side comparison of the MASLD and MAFLD diagnostic criteria. This table is intended to enhance clarity and facilitate direct evaluation of the respective definitions, highlighting both overlapping features and key distinctions—particularly in terms of metabolic thresholds and required criteria. We believe this addition strengthens the manuscript’s methodological transparency and supports its relevance in the context of the ongoing terminological transition.

4. The main finding—that MAFLD performs better in lean patients—should be discussed more mechanistically. Why might HOMA-IR and hs-CRP capture fibrosis risk more accurately than MASLD’s simplified cardiometabolic factors?

Reply: We thank the reviewer for the valuable suggestion and have expanded the discussion to provide a mechanistic rationale for the observed superiority of MAFLD criteria in predicting advanced fibrosis (AF) progression among lean individuals. While no statistically significant differences were observed between MASLD and MAFLD in non-lean (NL) patients (p = 0.076), MAFLD demonstrated a significantly enhanced predictive capacity in lean (L) subjects (p = 0.006). This divergence may be attributed to the confounding influence of visceral adiposity in NL individuals, which can obscure the contribution of discrete metabolic drivers. In contrast, the lean phenotype allows for a clearer delineation of independent pathophysiological mechanisms.

Specifically, MAFLD incorporates HOMA-IR and hs-CRP—markers that reflect insulin resistance and systemic inflammation, respectively—both of which are mechanistically implicated in hepatic fibrogenesis. Insulin resistance promotes hepatic lipotoxicity, oxidative stress, and stellate cell activation, thereby accelerating fibrotic remodeling. Concurrently, elevated hs-CRP levels denote extra-hepatic inflammatory burden, which may amplify hepatic injury through cytokine-mediated pathways, simultaneously correlating with liver disease progression and body composition status. These mechanisms are particularly relevant in lean individuals, where overt cardiometabolic features (e.g., hypertension, dyslipidemia) may be absent or less pronounced, limiting the sensitivity of MASLD’s simplified criteria. Our multivariable analysis confirmed that T2DM (p = 0.001), HOMA-IR (p = 0.02), and hs-CRP (p = 0.03) were independently associated with increased AF risk in lean patients, reinforcing the biological plausibility of these findings.

Altogether, these data suggest that MAFLD’s inclusion of mechanistically grounded biomarkers enhances its discriminatory power in metabolically vulnerable but phenotypically lean populations, offering a more nuanced approach to fibrosis risk stratification.

5. The absence of difference in HCC or ACE incidence between definitions is an important negative finding. The authors should discuss whether the short follow-up (3 years) and limited events may have obscured real differences.

Reply: We thank the Reviewer for this relevant consideration. As suggested, in the resubmitted version of our manuscript, we have highlighted the different motivations that guided the choice of the time point of 3-year risk in conceiving the experimental design: << […] a brief observation period (three years) was voluntarily considered with the aim of simulating the short-term repercussions in terms of disease progression (both liver-related and ACEs) of labeling “MASLD” or “MAFLD” in everyday clinical practice. On the other hand, equally consistent with the routinary reproducibility, a practical reason guided the identification of this relatively short interval, considering it is unlikely for MASLD patients to transition to MAFLD (and vice-versa) within such a restricted period in real-life scenarios. In line with this, in our observation, no patient transitioned (from MASLD to MAFLD and vice versa) within 36 months. Anyway, this experimental design opens to future perspectives, and does not preclude the realization of future research contemplating an enlargement of the follow-up period with the dynamical evaluation of potentially occurring transition […] >>.

However, besides preventing this possible transition, evidence-based findings sustained the choice of such a limited interval of observations in our experimental design. In particular, concerning HCC, as widely described, in the dysmetabolic context (NAFLD/MAFLD/MASLD), a higher risk of HCC occurrence is not limited to advanced chronic liver disease (ACLD)/liver cirrhosis scenarios, and it has been reported even in the advanced fibrosis stage (>F3 - AF) [Wang X et al, Molecular mechanisms in MASLD/MASH-related HCC. Hepatology. 2024; Provera A, et al., From MASLD to HCC: What's in the middle? Heliyon. 2024]. In line with this, as illustrated in the results, patients were further stratified according to fibrosis severity in the analysis, and consistently, a higher incidence rate of HCC in patients presenting fibrosis > F3 (i.e., AF) was reported. On the other hand, diabetes, representing a crucial cardiometabolic factor configuring the “metabolic dysfunction” in MASLD and MAFLD, is also a well-recognized independent risk factor for both HCC  and ACEs [Meroni, M et al. Cardiometabolic Risk Factors in MASLD Patients with HCC: The Other Side of the Coin. Front Endocrinol (Lausanne) 2024], contributing thus to enhancing the risk of this neoplasm and ischaemic events, independently (both from a chronological and physiopathological point of view) from the liver disease progression status of the underlying chronic hepatic disorder. In our case, this evidence appears even more relevant considering that a significant part (NL-SLD 38.21% and L-SLD 28.57%) of our study population presented decompensated type 2 diabetes mellitus at the baseline.

Finally, focusing more deeply on the duration of follow-up for HCC, more recently, a multicentric study revealed the impact of acute lifestyle changes on steatosis evolution: a large cohort of patients was followed two years pre- and two years during the lockdown social restrictions in three Italian medical centers [Dallio M, The influence of acute lifestyle changes on NAFLD evolution in a multicentre cohort: a matter of body composition. Nutr Diabetes. 2024]. Simultaneously with lifestyle modifications (decreased physical exercise and increased food intake), associated with changes in body composition, the lockdown (i.e., 2 years interval) overall HCC and Milan-out HCC occurrence revealed Hazard Ratio (HR): 2.398, 95% Confidence Interval (CI):1.16-5, p = 0.02, and HR:5.931, CI:2-17.6, p = 0.008 respectively. Consistent with this, considering that the screened (and then potentially enrolled) patients in our study were admitted between January 2016 and May 2021, a significant portion of the cohort experienced this peculiar period. These findings highlight how, even in a short period (“acute”), lifestyle changes may impact FLD worsening, negatively influencing HCC occurrence.

All the above-presented motivations guiding the choice of time point of 3-year risk in designing the experiment are reported and/or have been added, after opportunely referencing, in the resubmitted version of the discussion.

6. The authors suggest revising MASLD criteria to reintroduce hs-CRP and HOMA-IR—this is provocative but should be framed as a hypothesis for future validation, not a definitive recommendation.

Reply: We appreciate the Reviewer’s thoughtful observation. In response, we have revised the manuscript to clarify that our findings do not constitute a definitive recommendation but rather support a hypothesis warranting future validation. Specifically, the observed associations between hs-CRP, HOMA-IR, and advanced fibrosis progression—particularly in lean individuals—suggest that these markers may enhance the discriminatory power of diagnostic frameworks. Accordingly, we propose that the potential reintroduction of hs-CRP and HOMA-IR into MASLD-defining criteria be considered as a subject for further prospective investigation, ideally within larger and more diverse cohorts.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

thank you very much for submitting your manuscript. Please find the reviewer´s report down below.

Kind regards.

 

Reviewers´s report

Summary:

In the present retrospective study, the authors evaluate the diagnostic criteria of MASLD and MAFLD based on patient data. The aim of this study was to assess advanced fibrosis progression, hepatocellular carcinoma, and the first occurrence of acute cardiovascular events in steatotic liver disease patients over a short period of 3 years.

 

General comment on the hypothesis of the work:

The present study is very interesting. The authors were able to demonstrate that adjusting the MASLD and MAFLD criteria offers no advantage in assessing underlying steatosis and the severity of fibrosis. In lean steatotic liver disease patients, the authors could deduce a preventive effect of MAFLD criteria.

The introduction is too superficial and does not go into depth on key aspects. For example, the authors describe the low pre-weaning mortality rate of Meishan pigs compared to crossbred pigs. However, it does not provide specific mortality rates for either breed.

The materials and methods section lack some necessary information on the materials used. However, the figures 1A and 1B have to be optimized according to the comments below.

In the results, the tables and figures must be described in greater detail and adjusted in their presentation.

The discussion refers to the results and places them in relation to the current literature. However, effects of the SARS CoV-2 pandemia must be discussed.

 

Comments on the Abstract:

L21: Please write out the abbreviation HCC.

L26: n = 134; n = 797

L27: n = 206; n = 481; n = 110; n = 39

L28: n = 68; n = 27

L30: p ≤ 0.076

L32: p ≤ 0.006

L33: Please write out the abbreviation aHR.

LL33-34: aHR = 2.113; p ≤ 0.001; aHR = 1.441; p ≤ 0.02

L35: aHR = 1.228; p ≤ 0.03

L37: C.I. 95% (missing space)

L38: p ≤ 0.741; C.I. 95%; p ≤ 0.701

 

Comments on Material and Methods:

LL92-93: Please add the full name and city of the University.

L114: What means DILI?

LL115-116: Did you mean malnutrition threw viral hepatitis?

L121: Which forms of psychiatric problems?

LL130-131: Please list the main causes of death.

L138: Body-Mass-Index < 25 kg/m² (missing space); n = 134; n = 797

L140: n = 206; n = 481; n = 110; n = 39

L141: n = 27

L144: attack (TIA) (missing space)

L146: n = 180

L147: n = 301; n = 98

L148: n = 26

L165: < 25 kg/m² (missing space)

L166: n = 206; n = 481

L167: n = 39; n = 68; n = 27

L168: n = 180; n = 301; n = 98

L169: n = 39; n = 66; n = 26

LL169-171: Better in a new paragraph. The abbreviations apply for both figures.

L191 ‘presence of ≥ one’ Is that symbol wrong placed? Its better to write the term one as number.

L193: ≥ 150 mg/dl (missing space)

L194: < 50 mg/dl (missing space)

L198: > 25 kg/m² (missing space)

L199: > 102 cm (missing space)

L200: > 130 mmHg; > 150 mg/dL (missing space)

L201: < 40 mg/dl; 50 mg/dL (missing space)

L202: 100-125 mg/dL

L203: > 2.5 (missing space)

L204: > 2 mg/L (missing space)

LL208-213: You describe in LL228-229 the material for diagnostic used as well as the manufacturer, city and national state. Please add similar information for the ultrasonography.

LL215-224: You describe in LL228-229 the material for diagnostic used as well as the manufacturer, city and national state. Please add similar information for the clinical and biochemical analyses.

L229: > 30 (missing space)

L230: > 2.5 cm (missing space)

L232: Boursier et al. [19]

L233: Please write out the abbreviation IQR.

L246: > 67%; ≥ 293 dB/m (missing space)

LL254-256: Did you use the asterisk as multiplication symbol? In LL258-260 you use x as multiplication symbol. Please use uniform mathematical operators for the formulas.

L256: < 1.45 (missing space)

L257: > 3.25 (missing space)

L259: + 1.13; + 0.99 (missing space)

L262: ≥ 0.8; ≥ 28 (missing space)

L264: AF [25] (missing space)

L278: Please add the abbreviations for mean and standard deviation.

L298: Please add the manufacturer, city and national state for GraphPad Prism.

L302: n = 110

L303: significance: p ≤ 0.05

L303: Please add the manufacturer, city and state for STATA14.

 

Figure 1:

A: Please show the text in the figure in larger size.

B: It is better to place the vector graphics of lean and not-lean above the ring diagrams. The line with the total number of patients could be placed below the diagrams.

Please add CLD, CRF, EMR, BMI, ACCD, LTE and TOT to the description of the figure and write out.

 

Comments on the Results:

L312: Please add the difference of age in mean with SD.

L314: Pleas add the prevalence values.

L315: p ≤ 0.005

L316: p ≤ 0.0005; p ≤ 0.0007

L318: p ≤ 0.005; n = 180

L319: n = 14

L326: p ≤ 0.04; p ≤ 0.03

L327: p ≤ 0.002≤≤≤

LL329-334: Please add the unit % to the prevalence values.

LL348-351: To what total numbers of patients do the percentage refer?

LL353, 355, 357, 360, 365, 366: C.I. 95% (missing space)

LL357-358: p ≤ 0.076

L367: p ≤ 0.006

L370: p < 0.0001; p ≤ 0.002; p ≤ 0.03

L371: p ≤ 0.02

L372: p < 0.0001 (missing space)

L374: p ≤ 0.001; p ≤ 0.02; p ≤ 0.03

L384: p ≤ 0.741

L387: p ≤ 0.735

L389: p ≤ 0.313

L394: p ≤ 0.321

LL394-395: p ≤ 0.288

L397: C.I. 95% (missing space)

L398: p ≤ 0.701

L400: p ≤ 0.664

L422: p ≤ 0.606

L425: p ≤ 0.265

L428: C.I. 95%; p ≤ 0.997

L431: p ≤ 0.917

 

Table 1:

Please add the abbreviations BMI, LSM, CAP, MedDiet and n.s. to the description of the table and write out.

 

Figure 2:

Please present Fig. 2 in larger size.

Please describe Panel D as separate item, according to the other three panels.

Please add the abbreviations MASLD, MAFLD and n.s. to the description of the figure and write it out.

The p values in the diagrams: A p ≤ 0.103; B p ≤ 0.277; C p ≤ 0.163; D p ≤ 0.716

 

Figure 3:

It is better to present both diagrams in the same size. The diagram ‘HCC occurrence according baseline fibrosis stage’ is difficult to read.

Please add the abbreviations MASLD and MAFLD to the description of the figure and write out.

The p values in the diagrams: A p ≤ 0.741; p ≤ 0.313; p ≤ 0.502; B p ≤ 0.701

 

Figure 4:

Please add the abbreviations MASLD and MAFLD to the description of the figure and write out.

The p values in the diagram: A p ≤ 0.606; B p ≤ 0.997

 

Comments on the Discussion:

L456: Yamamura et al. [29] (not in italic style)

L459: Lin et al. [30] (not in italic style)

L475: Song et al. [34] (not in italic stiyle)

L483: p ≤ 0.076

L486: p ≤ 0.006

L489: p ≤ 0.001

L490: p ≤ 0.02

L496: Please explain the abbreviation MASH.

L506: p ≤ 0.664

L534: Restrictions during corona pandemic? Please add the information.

L537: What does Milan-out HCC mean?

L538: p ≤ 0.02; p ≤ 0.008

L539: respectively] [45] (missing space)

LL540-546: You wrote that a significant cohort in your study experienced the lockdown. Did you have data about SARS-CoV2 infections of these patients? Could this have an impact on your existing data? Please discuss possible effects of SARS-CoV2.

L559: T2DM [42] (missing space)

 

Other comments:

L591: (or Ethics Committee) of the (word doubling)

LL688-691: Please check the citation style of this reference.

Author Response

General comment on the hypothesis of the work:

The present study is very interesting. The authors were able to demonstrate that adjusting the MASLD and MAFLD criteria offers no advantage in assessing underlying steatosis and the severity of fibrosis. In lean steatotic liver disease patients, the authors could deduce a preventive effect of MAFLD criteria.

• The introduction is too superficial and does not go into depth on key aspects. For example, the authors describe the low pre-weaning mortality rate of Meishan pigs compared to crossbred pigs. However, it does not provide specific mortality rates for either breed.
• The materials and methods section lack some necessary information on the materials used. However, the figures 1A and 1B have to be optimized according to the comments below.
• In the results, the tables and figures must be described in greater detail and adjusted in their presentation.
• The discussion refers to the results and places them in relation to the current literature. However, effects of the SARS CoV-2 pandemia must be discussed.

Reply: We sincerely thank the Reviewer for His/Her relevant comments. In the resubmitted version of our manuscript, the introduction has been properly expanded and all the other issues have been fixed, following the Reviewers’ suggestions (see the specific points below). Unfortunately, we were not able to find (and thus, to fix) “[…] the low pre-weaning mortality rate of Meishan pigs compared to crossbred pigs[…]” which does not represent a passage or a concept presented in the introduction of our paper.

 

Comments on the Abstract:

• L21: Please write out the abbreviation HCC.
• L26: n = 134; n = 797
• L27: n = 206; n = 481; n = 110; n = 39
• L28: n = 68; n = 27
• L30: p ≤ 0.076
• L32: p ≤ 0.006
• L33: Please write out the abbreviation aHR.
• LL33-34: aHR = 2.113; p ≤ 0.001; aHR = 1.441; p ≤ 0.02
• L35: aHR = 1.228; p ≤ 0.03
• L37: C.I. 95% (missing space)
• L38: p ≤ 0.741; C.I. 95%; p ≤ 0.701

Reply:  We sincerely thank the Reviewer for these relevant notifications. In the resubmitted version, all these issues have been properly fixed and modified in the abstract.

 

Comments on Material and Methods:

• LL92-93: Please add the full name and city of the University

Reply: We have added the full name and city of the University

 

• L114: What means DILI?

Reply: We have clarified “DILI” (drug-induced liver injury)

 

• LL115-116: Did you mean malnutrition threw viral hepatitis?

Reply:  We thank the Reviewer for this comment. We mean chronic viral infection (including HCV) causes, which are inserted in the “Miscellaneous” section of the official Flowchart Delphi consensus. Therefore, we reported consistently what was established in the consensus. [Rinella ME, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology. 2023 PMID: 37363821] (see Flowchart below attached]

 

• L121: Which forms of psychiatric problems?

Reply: We sincerely thank the Reviewer for this relevant notification.  The integrity of informed consent may be compromised in individuals affected by certain psychiatric disorders, particularly when these conditions impair cognitive function, judgment, or decisional capacity. Disorders such as severe depression, psychosis, bipolar disorder in manic or depressive phases, and major neurocognitive disorders (e.g., dementia) can interfere with the participant’s ability to comprehend study-related information, appreciate potential risks and benefits, and make voluntary decisions.  In the resubmitted version of our manuscript, all these features have been properly clarified in the section dedicated to the description of the selection process, and the psychiatric problems considered as disorders impacting the validity of informed consent were extensively described.

 

• LL130-131: Please list the main causes of death.

Reply: We sincerely thank the Reviewer for this precious comment. In the revised version of our paper, we have added the main causes of death.

• L138: Body-Mass-Index < 25 kg/m² (missing space); n = 134; n = 797
• L140: n = 206; n = 481; n = 110; n = 39
• L141: n = 27
• L144: attack (TIA) (missing space)
• L146: n = 180
• L147: n = 301; n = 98
• L148: n = 26
• L165: < 25 kg/m² (missing space)
• L166: n = 206; n = 481
• L167: n = 39; n = 68; n = 27
• L168: n = 180; n = 301; n = 98
• L169: n = 39; n = 66; n = 26

Reply: We thank the Reviewer for these notifications, which have all been fixed in the revised version.

 

• LL169-171: Better in a new paragraph. The abbreviations apply for both figures.

Reply: We sincerely thank the Reviewer for this precious suggestion, and we completely agree. Therefore, since the abbreviations apply to both figures, the lines have been placed in a new paragraph.

 

• L191 ‘presence of ≥ one’ Is that symbol wrong placed? Its better to write the term one as number.

Reply: We thank the Reviewer for this notification. In the resubmitted version, the “presence of > one” was written as “presence of at least one”.

 

• L193: ≥ 150 mg/dl (missing space)
• L194: < 50 mg/dl (missing space)
• L198: > 25 kg/m² (missing space)
• L199: > 102 cm (missing space)
• L200: > 130 mmHg; > 150 mg/dL (missing space)
• L201: < 40 mg/dl; 50 mg/dL (missing space)
• L202: 100-125 mg/dL
• L203: > 2.5 (missing space)
• L204: > 2 mg/L (missing space)

Reply: We thank the Reviewer for these notifications. In the revised version, all the missing spaces have been properly added.

 

• LL208-213: You describe in LL228-229 the material for diagnostic used as well as the manufacturer, city and national state. Please add similar information for the ultrasonography.

Reply: We thank the Reviewer for this relevant comment. In the resubmitted version, the manufacturer, city, and state of the ultrasound machinery version were added.

• LL215-224: You describe in LL228-229 the material for diagnostic used as well as the manufacturer, city and national state. Please add similar information for the clinical and biochemical analyses.

Reply: We thank the Reviewer for this precious suggestion. In the resubmitted version, the manufacturer, city, and state of methods adopted to assess the biochemical analyses were added.

 

• L229: > 30 (missing space)
• L230: > 2.5 cm (missing space)
• L232: Boursier et al. [19]
• L233: Please write out the abbreviation IQR.
• L246: > 67%; ≥ 293 dB/m (missing space)
• LL254-256: Did you use the asterisk as multiplication symbol? In LL258-260 you use x as multiplication symbol. Please use uniform mathematical operators for the formulas.
• L256: < 1.45 (missing space)
• L257: > 3.25 (missing space)
• L259: + 1.13; + 0.99 (missing space)
• L262: ≥ 0.8; ≥ 28 (missing space)
• L264: AF [25] (missing space)
• L278: Please add the abbreviations for mean and standard deviation.
• L302: n = 110
• L303: significance: p ≤ 0.05

Reply: We thank the Reviewer for these notifications, which have all been fixed in the revised version.

 

• L298: Please add the manufacturer, city and national state for GraphPad Prism.
• L303: Please add the manufacturer, city and state for STATA14.

Reply: We thank the Reviewer for this precious suggestion. In the resubmitted version, the manufacturer, city, and state of both GraphPad Prism and STAT14 were added.

 

• Figure 1:
• A: Please show the text in the figure in larger size.
• B: It is better to place the vector graphics of lean and not-lean above the ring diagrams. The line with the total number of patients could be placed below the diagrams.
• Please add CLD, CRF, EMR, BMI, ACCD, LTE and TOT to the description of the figure and write out.

Reply: We sincerely thank the Reviewer for this precious suggestion. In the resubmitted version, Figure 1 has been properly modified: the text in panel A has been provided in a larger size; as suggested, the elements in panel B have been adequately replaced; finally, the clarifications of all the abbreviations have been reported in the description of the figure.

 

Comments on the Results:

• L312: Please add the difference of age in mean with SD

Reply: The age difference has been added in the main text.

 

• L314: Please add the prevalence values.

Reply: We have added prevalence values.

 

• L315: p ≤ 0.005
• L316: p ≤ 0.0005; p ≤ 0.0007
• L318: p ≤ 0.005; n = 180
• L319: n = 14
• L326: p ≤ 0.04; p ≤ 0.03
• L327: p ≤ 0.002≤≤≤
• LL329-334: Please add the unit % to the prevalence values.

Reply: We thank the Reviewer for these notifications, which have all been fixed in the revised version.

 

• LL348-351: To what total numbers of patients do the percentages refer?

Reply: We sincerely thank the Reviewer for this notification. As specified in the revised version of our manuscript, in this sentence, the percentages refer to the total number of NL-MASLD individuals not presenting baseline AF.

 

• LL353, 355, 357, 360, 365, 366: C.I. 95% (missing space)
• LL357-358: p ≤ 0.076
• L367: p ≤ 0.006
• L370: p < 0.0001; p ≤ 0.002; p ≤ 0.03
• L371: p ≤ 0.02
• L372: p < 0.0001 (missing space)
• L374: p ≤ 0.001; p ≤ 0.02; p ≤ 0.03
• L384: p ≤ 0.741
• L387: p ≤ 0.735
• L389: p ≤ 0.313
• L394: p ≤ 0.321
• LL394-395: p ≤ 0.288
• L397: C.I. 95% (missing space)
• L398: p ≤ 0.701
• L400: p ≤ 0.664
• L422: p ≤ 0.606
• L425: p ≤ 0.265
• L428: C.I. 95%; p ≤ 0.997
• L431: p ≤ 0.917

Reply: We thank the Reviewer for these notifications, which have all been fixed in the revised version of our manuscript.

• Table 1:
• Please add the abbreviations BMI, LSM, CAP, MedDiet, and n.s. to the description of the table and write out.

Reply: We thank the Reviewer for this notification. The abbreviations have been properly clarified and added in the description of Table 1 (which has now become Table 2)

• Figure 2:

Please present Fig. 2 in larger size.

Please describe Panel D as separate item, according to the other three panels.

Please add the abbreviations MASLD, MAFLD and n.s. to the description of the figure and write it out.

The p values in the diagrams: A p ≤ 0.103; B p ≤ 0.277; C p ≤ 0.163; D p ≤ 0.71

Reply: We sincerely thank the Reviewer for this precious suggestion. In the resubmitted version, Figure 1 has been properly modified: the figure has been presented in a larger size; panel D has been properly described; all the abbreviations have been clarified in the description of the figure; the p values have been properly reported in the diagrams. 

• Figure 3:
• It is better to present both diagrams in the same size. The diagram ‘HCC occurrence according baseline fibrosis stage’ is difficult to read.
• Please add the abbreviations MASLD and MAFLD to the description of the figure and write out.
• The p values in the diagrams: A p ≤ 0.741; p ≤ 0.313; p ≤ 0.502; B p ≤ 0.70

Reply: We sincerely thank the Reviewer for this precious suggestion. In the resubmitted version, Figure 3 has been properly modified: the figure has been presented in a proper size; all the abbreviations have been clarified in the description of the figure; the p-values have been properly reported in the diagrams.

• Figure 4:
• Please add the abbreviations MASLD and MAFLD to the description of the figure and write out.
• The p values in the diagram: A p ≤ 0.606; B p ≤ 0.997

Reply: We sincerely thank the Reviewer for this precious suggestion. In the resubmitted version, Figure 4 has been properly modified: all the abbreviations have been clarified in the description of the figure; the p-values have been properly reported in the diagrams.

 

Comments on the Discussion:

• L456: Yamamura et al. [29] (not in italic style)
• L459: Lin et al. [30] (not in italic style)
• L475: Song et al. [34] (not in italic stiyle)
• L483: p ≤ 0.076
• L486: p ≤ 0.006
• L489: p ≤ 0.001
• L490: p ≤ 0.02
• L496: Please explain the abbreviation MASH.
• L506: p ≤ 0.664
• L538: p ≤ 0.02; p ≤ 0.008
• L539: respectively] [45] (missing space)
• L559: T2DM [42] (missing space)
• Reply: We thank the Reviewer for these notifications. All of these have been fixed in the revised version of our manuscript, as well as the abbreviations have been properly clarified.

• L537: What does Milan-out HCC mean?

Reply:  We thank the Reviewer for this notification. With this expression, we indicate the HCC presenting outside the Milan Criteria (i.e., out of the criteria for considering transplantation). As suggested, to increase the readability of this passage, we have added “criteria” to this standardized, largely recognized, and well-known definition. 

• L534: Restrictions during corona pandemic? Please add the information.

Reply: We sincerely thank the Reviewer for this suggestion. During the lockdown, social restrictions included stay-at-home orders, closure of public venues, limits on gatherings, travel bans, and mandatory distancing measures to reduce viral transmission were adopted. As suggested, this information has been properly added to the revised version of our paper.

• LL540-546: You wrote that a significant cohort in your study experienced the lockdown. Did you have data about SARS-CoV2 infections of these patients? Could this have an impact on your existing data? Please discuss possible effects of SARS-CoV2

Reply: We sincerely thank the Reviewer for this relevant and valuable suggestion. In the revised version, we have discussed the possible effects of SARS-CoV-2 infection. In particular, as properly reported in the resubmitted version of our paper in the discussion section, the pandemic period had a potential indirect effect on the observed outcomes in our cohort. In this sense, a multicenter investigation demonstrated the influence of abrupt lifestyle alterations on the progression of steatotic liver disease (SLD). A substantial patient cohort was monitored across two distinct phases—two years preceding and two years during the COVID-19 lockdown period—characterized by stringent social restrictions (including stay-at-home mandates, closure of public facilities, limitations on social gatherings, travel prohibitions, and compulsory physical distancing measures aimed at mitigating viral transmission) across three Italian healthcare institutions. Concomitant with lifestyle disruptions—defined by decreased physical activity and increased caloric intake—resulting in measurable changes in body composition, the lockdown interval (spanning two years) was associated with a significantly elevated risk of hepatocellular carcinoma (HCC), both in overall incidence and among cases exceeding Milan criteria [Hazard Ratio (HR): 2.398, p = 0.02; HR: 5.931, p = 0.008, respectively], independent of baseline hepatic fibrosis severity and the availability of surveillance protocols during the pandemic. In alignment with these findings, it is noteworthy that the recruitment window for the present study (January 2016 to May 2021) encompassed the lockdown period, thereby exposing a substantial subset of the cohort to its effects. Specifically, among the 931 enrolled participants, 410 (44.03%) experienced the full duration of social restrictions, accompanied by a discernible deterioration in lifestyle behaviors (reduced physical activity and increased food consumption). Although none of these individuals developed severe SARS-CoV-2-related complications or hepatic manifestations during infection, the imposed limitations likely contributed to the observed outcomes through alterations in body composition. Collectively, these data underscore the potential for short-term (“acute”) lifestyle perturbations to exacerbate SLD progression and increase HCC risk. Nonetheless, the design of the present study should be regarded as exploratory and innovative, offering preliminary insights while laying the groundwork for future investigations with extended follow-up durations.

Other comments:

• L591: (or Ethics Committee) of the (word doubling)
• LL688-691: Please check the citation style of this reference.

Reply: We thank the Reviewer for these notifications, which have all been fixed and checked in the revised version of our manuscript.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

thank you very much for incorporating my comments. The manuscript and the figures are much better. The sampling and tests used are more comprehensible in the Materials and Methods section. The presentation of the results in the figures is clearly understandable for the reader and visually illustrates the results. The discussion has become more detailed with the additional aspects and highlights the results.

I have only a few further comments:

L101: (Naples, Italy) (missing bracket)

L283: Age x AST(U/L) You use an asterisk and an x as mathmatical sign for multiplication. Please use uniform signs.

LL570-571: This sentence was probably crossed out during editing. Please remove this sentence from the manuscript or remove the strikethrough formatting.

L871: Please use the abbreviation of the cited journal according to the guidelines of the journal.

Kind regards.

Author Response

Dear authors,

thank you very much for incorporating my comments. The manuscript and the figures are much better. The sampling and tests used are more comprehensible in the Materials and Methods section. The presentation of the results in the figures is clearly understandable for the reader and visually illustrates the results. The discussion has become more detailed with the additional aspects and highlights the results.

I have only a few further comments:

• L101: (Naples, Italy) (missing bracket)

Reply: We sincerely thank the Reviewer for this notification: a bracket has been added.

• L283: Age x AST(U/L) You use an asterisk and an x as a mathematical sign for multiplication. Please use uniform signs.

Reply: We are sorry for this mistake. In the revised version, the mathematical sign has been harmonized and uniformed by using “×”.

• LL570-571: This sentence was probably crossed out during editing. Please remove this sentence from the manuscript or remove the strikethrough formatting.

Reply: We are sorry for this mistake: we have removed the indicated sentence.

• L871: Please use the abbreviation of the cited journal according to the guidelines of the journal.

Reply: We sincerely thank the Reviewer for this notification: the correct abbreviation (Arch Med Res) for the cited journal was adopted.

Author Response File: Author Response.pdf