The authors would like to thank Zoncape and Tsochatzis [1] for their interest in our paper titled “Risk assessment of hepatitis B virus-related hepatocellular carcinoma development using vibration-controlled transient elastography: Systematic review and meta-analysis [2]” and their feedback.

As mentioned by Zoncape and Tsochatzis [1], we acknowledge that the results of our article [2] have several limitations despite its clinical utility in predicting the risk of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients. All the studies included in our systemic review and meta-analyses were conducted on Asian populations [2], which limits the generalizability of our results. Therefore, it is necessary to conduct multinational studies to generalize our results globally. Nevertheless, our findings are expected to be beneficial for managing CHB patients in areas where hepatitis B virus infection is prevalent [1]. Another issue raised by Zoncape and Tsochatzis [1] was the potential influence of antiviral treatment, which is significantly associated with a reduced risk of HCC development [3-6]. Due to variations in the types of antiviral drugs and their usage criteria depending on when the studies were conducted, it was challenging to perform subgroup analyses based on the status of the antiviral treatment.

Furthermore, as indicated by Zoncape and Tsochatzis [1], the hepatitis B e antigen (HBeAg) status or the duration of antiviral treatment are also important factors in determining the risk of HCC development [5,7]. However, our study had several limitations related to these factors. First, HBeAg positive and negative patients were mixed in the included studies, making it difficult to analyze them separately because our study was not based on an individual patient database [2]. Second, despite the slight differences between studies, it was found that antiviral therapy was administered for at least 24 months. Additionally, as described in the discussion of our article [2], the included study was not a randomized controlled trial, and several confounding vari-ables such as the duration of antiviral treatment, alcohol history, or combined metabolic variables could not be strictly controlled as noted by Zoncape and Tsochatzis [1]. Given these limitations, caution is needed when interpreting the results of our research.

Lastly, we agree with Zoncape and Tsochatzis [1] that there can be limitations in assessing the risk of HCC development using a single tool. In our study, we focused on the ability of transient elastography (TE) to predict the risk of HCC development based on liver stiffness (LS) cutoff value [2]. As individual patient data could not be obtained in our meta-analysis [2], combined analyses could not be performed using multiple noninvasive methods [8-15]. However, combining well-known noninvasive methods or other clinical/laboratory parameters [8-15] to complement the LS cutoff determined by TE is expected to enable a more accurate assessment of HCC development risk as Zoncape and Tsochatzis [1] mentioned.

In summary, the TE-determined LS values may assist in making a risk prediction of HCC development in CHB patients. Moreover, we expect that TE can be used to facilitate the development of optimal HCC surveillance strategies in CHB patients.