Dear Editor,

We thank the author of the letter for his comments on our study, “Prevalence and Risk Factors of Significant Hepatic Fibrosis in Omani Patients with HBeAg-negative Chronic Hepatitis B Virus Infection,”1 particularly regarding the reference standards for liver stiffness cut-off values (LSCOVs).

We agree that liver biopsy (LB) remains the gold standard for assessing liver fibrosis, as it provides direct histopathologic evaluation of hepatic architecture, allowing accurate staging and grading of chronic liver disease.2 Although noninvasive methods such as two-dimensional shear-wave elastography (2D-SWE) are increasingly used in clinical practice because of their safety and reproducibility, their diagnostic performance depends substantially on the reference method used to establish LSCOVs.3

In our study, we adopted LSCOVs referenced to transient elastography because these thresholds were widely reported in regional literature and provided pragmatic benchmarks for noninvasive fibrosis staging.4 However, we acknowledge the limitation that transient elastography itself is a noninvasive modality and may not provide the same level of diagnostic precision as LB.5

We agree that LB-derived reference values for 2D-SWE, such as those reported by Aksakal et al,6 offer a more robust foundation for evaluating liver stiffness. Such thresholds may enable more accurate differentiation between fibrosis stages, thereby enhancing the diagnostic performanceof 2D-SWE. Future research in our region incorporating LB-validated cut-off values would further strengthen the clinical applicability of elastography in managing chronic hepatitis B virus infection.

We also concur with the author’s concluding point: irrespective of the diagnostic method, periodic monitoring of inactive hepatitis B virus carriers is essential for early detection of fibrosis progression and optimization of long-term outcomes.

references

1. Al-Shuaili HH, Al Mashikhi B, Al Sinani A, Al-Busafi SA. High prevalence and risk factors of significant hepatic fibrosis in Omani patients with HBeAg-negative chronic hepatitis B virus infection: a retrospective study. Oman Med J 2024;39(6):e693.
2. 2. Chowdhury AB, Mehta KJ. Liver biopsy for assessment of chronic liver diseases: a synopsis. Clin Exp Med 2023 Jun;23(2):273-285.
3. 3. European Association for Study of Liver; Asociacion Latinoamericana para el Estudio del Higado. EASL-ALEH clinical practice guidelines: non-invasive tests for evaluation of liver disease severity and prognosis. J Hepatol 2015 Jul;63(1):237-264.
4. 4. Sporea I, Bota S, Gradinaru-Taşcău O, Sirli R, Popescu A, Jurchiş A. Which are the cut-off values of 2D-Shear Wave Elastography (2D-SWE) liver stiffness measurements predicting different stages of liver fibrosis, considering transient elastography (TE) as the reference method? Eur J Radiol 2014 Mar;83(3):e118-e122.
5. 5. Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD; American Association for the study of liver diseases. Liver biopsy. Hepatology 2009 Mar;49(3):1017-1044.
6. 6. Aksakal M, Oktar SO, Sendur HN, Esendaglı G, Ozenirler S, Cindoruk M, et al. Diagnostic performance of 2D shear wave elastography in predicting liver fibrosis in patients with chronic hepatitis B and C: a histopathological correlation study. Abdom Radiol (NY) 2021 Jul;46(7):3238-3244.