Review for 10.1186/s12876-025-03957-1 (2025)

Title: Visceral adiposity index as a predictor of metabolic dysfunction–associated steatotic liver
disease: a cross-sectional study
Version: 0 Date: 05 Apr 2025
Reviewer's report:
The manuscript explores the potential role of VAI in patients with MASLD. While the topic
is clinically relevant, particularly in the evolving framework of MASLD, the manuscript in
its current form does not add significant novelty to the existing literature. Similar analyses
using the NHANES database, including a recent study (DOI: 10.1155/cjgh/5871321), have
already assessed the diagnostic role of VAI in MASLD, with comparable methodology and
conclusions. Additionally, limiting the study to only one non-invasive index weakens the clinical
and scientific impact. Substantial improvements are needed before this manuscript could be
considered for publication.
Major Comments
Lack of Novelty and Overly Simplistic Study Design
• Several studies have already assessed the relationship between VAI and MASLD using
the NHANES population, including articles published in March 2025 (DOI: 10.1155/
cjgh/5871321). The current manuscript largely duplicates this approach without offering
significant additional value or differentiation.
• The manuscript would benefit from a comparative analysis involving multiple non-invasive
scores (e.g., FIB-4, NFS, FLI, HSI, TyG index, LAP, or others). Including and contrasting
multiple biomarkers could help generate more meaningful insights and would significantly
improve the value of the paper.
• Evaluating these scores according to the grading and severity of hepatic steatosis and liver
fibrosis as evaluated using CAP and LSM would be a significant addition to the manuscript.
• The authors should consider either incorporating a panel of non-invasive scores or providing
more sophisticated analysis (e.g., predictive modeling, ROC comparisons, decision curve
analysis).
Introduction
• The introduction should better highlight what gap this study fills in the current literature,
especially considering VAI has been studied in NAFLD before. How does MASLD shift the
clinical utility or interpretation of VAI?
Methods:
Study Design and Population
• The criteria for MASLD should be described in more detail. MASLD diagnosis doesn't only
depend on the presence of hepatic steatosis. Please verify the MASLD diagnosis criteria and
add the proper reference.
• It was mentioned that hepatic steatosis was evaluated using CAP. However, several details
are missing. Please add more details related to the method of evaluating hepatic steatosis/liver
fibrosis.
Statistical Analysis
• The statistical methodology lacks detail. Please provide information on:
o Please describe the adjusted models for potential confounders.
o Were collinearity or interaction terms considered, especially given the overlap of VAI
components with MASLD diagnostic criteria?
Discussion
• Compare your results to other published studies that evaluated the same topic in other
populations, as well as other non-invasive biomarkers/scores in assessing MASLD. Also, please
add the clinical implications of the obtained results.
• The authors report a correlation between VAI and MASLD severity. However, correlation
does not imply causation. Please add a paragraph in the discussion section mentioning the study
limitations.
• The manuscript could benefit from a deeper discussion on the clinical implications of VAI
in MASLD.
Conclusions
• The last sentence from the conclusion should be removed as it is not related to the obtained
results.
Terminology
• Ensure consistent use of the term MASLD throughout the manuscript. Avoid mixing with
NAFLD.
Table 2
• Please include what each model (1, 2, 3) represent.