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We thank Ratziu et al for their interest in our work.1 To grade steatosis, we used the Metavir scoring system, shown by their group to be accurate and reproducible.2,3 Worsening was characterised by an increase in the amount of lipids in hepatocytes, as defined in this grading system. As emphasised in our paper, our main finding was that worsening of steatosis was the only independent factor associated with fibrosis progression in multivariate analysis. This study was observational and not aimed at establishing causal links, a goal that requires a combination of prospective clinical studies and careful in vitro experiments. Ratziu’s discussion of our data is interesting but remains purely speculative.1 The issues raised by our results and their discussion in both our paper and Ratziu’s letter are currently being addressed through appropriate studies in our centre.
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