We thank Drs Morozov and Batskikh for their interest in our article and appreciate the opportunity to respond to their concerns.1, 2 Specifically, they had two main issues. The first was that treatment with entecavir and tenofovir disoproxil fumarate (TDF) can cause hepatic steatosis and may be the intervening confounder rather than steatosis itself in the inhibition of viral replication. The second concern was that advanced fibrosis can still occur in the presence of hepatic steatosis irrespective of the presence of dyslipidemia suggesting that viral-induced changes continue to occur.1

These are excellent points. Regarding the first point, the studies selected for this meta-analysis did not present data on whether patients were receiving treatment and / or the type of treatment received. Therefore we were not able to include this information. We suggest that future studies on the effect of hepatic steatosis and HBV investigate the role of treatment in the development of steatosis and subsequent fibrosis development.

Regarding the second point, in the study that the authors cited, steatosis and fibrosis were diagnosed by fibroscan, different than what was used in most studies.3, 4 As such, their findings need to be replicated now that non-invasive testing for steatosis is more common. However, impeding the progress of using fibroscan for the diagnosis of steatosis is the exact level of kPa that needs to be present in order to correctly diagnose steatosis and liver stiffness measures that are needed to reflect both significant and advanced fibrosis among those with steatosis.5 In addition, accurate fibroscan results are highly dependent on both the operator and the probe used to obtain the measurements. Nonetheless, the authors raise a valid point and we agree that further investigation is warranted.6

The authors' declarations of personal and financial interests are unchanged from those in the original article.2

Author Contributions: Mindie Nguyen: Advisory board/consultation: Jansen, Gilead, Intercept; Research support: Gilead, Pfizer, Enanta.