We thank Bhushanali et al for their thoughtful comments on our recent study regarding hepatic steatosis grading using vibration-controlled transient elastography and the incorporation of time-varying predictors in assessing long-term hepatocellular carcinoma (HCC) risk.1 2

Currently, there are no universally validated cut-off values of controlled attenuation parameter (CAP) to define steatosis grades. CAP values are influenced by aetiology, diabetic status, body mass index, sex and aspartate transaminase levels. An individual patient data meta-analysis reported optimal CAP cut-offs to discriminate any hepatic steatosis (S1–S3) and moderate-to-severe steatosis (S2–S3) for HCV or HBV infection as 230 dB/m (95% CI 209 to 266) and 264 dB/m (95% CI 238 to 285), respectively. These differ from cut-offs reported for non-alcoholic fatty liver disease (249 and 310 dB/m) and alcohol-associated liver disease (274 and 268 dB/m).3 Prior studies in HCV have adopted a CAP threshold of ≥248 dB/m to define hepatic steatosis.4–7