Dear Dr. Mettananda,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Dear Authors, the manuscript entitled "Adoption and validation of the European Association for the Study of the Liver algorithm for the noninvasive diagnosis of advanced fibrosis in metabolic dysfunction-associated steatotic liver disease in low-resource South Asian settings", is a reasonable proposal to use resources in clinical scenarios where resources are limited, however it needs some adjusments:

- In table 1, complete all parenthesis

- In table I, use the universal recognized categories for BMI according to cut-off values. You may need to recalculate the frequencies.

- In table I, divide the waist by sex and treat it as a numeric discrete variable. Waist itself is related to liver steatosis and could be a great prognosis factor to MASLD, however it requieres a better statistical treatment, I suggets that you could consider it.

- Explain the importance to divide by ethnic groups, if there is no another analysis with this variable, is enough to stablish "Sinhalese" and "other ethnicities" (Tamil, Muslim, Burgher, etc.)

- Describe the reasons why 7 participants were lost.

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Sophia Eugenia Martínez-Vázquez, Ph.D.

Academic Editor

PLOS One

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“This study was supported by the Grant RC/2024/03  of the University of Kelaniya, Sri Lanka, awarded to Chamila Mettananda.”

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Dear authors, Thank you for this work. Here are my comments for more clarity:

# Refine the introduction and problem statement: While the introduction effectively highlights the burden of MASLD and T2DM, consider strengthening the rationale for developing a new criterion for VCTE referral. Emphasize why the existing EASL algorithm might be insufficient or impractical in low-resource South Asian settings, beyond just reducing referrals.

# Patient selection: Provide more details on the inclusion and exclusion criteria for both the primary and external validation cohorts. For instance, were patients with other liver diseases excluded?

# AUC-ROC values: While AUC-ROC values are provided, consider including confidence intervals for these values to indicate the precision of the estimates.

Reviewer #2: 1.The manuscript is technically sound. The study design is appropriate for validating a modified algorithm, and the data generally support the conclusions: multivariable logistic regression identifies independent predictors of SF/ACLD, and the new criterion reduces VCTE referrals while maintaining reasonable sensitivity (81.6% vs. 88.2% for EASL) and improving specificity (53.3% vs. 35.6%). The external validation strengthens the findings.

2.The statistical methods are appropriate for the study design. The use of multivariable logistic regression to identify independent predictors is standard. Performance metrics (sensitivity, specificity, PPV, NPV) and AUC-ROC for the algorithms are correctly calculated and presented. The comparison of referral numbers between the original and modified algorithms is straightforward and valid. The analysis is clearly described in the methods.

3.The authors state that data cannot be shared publicly due to ethical restrictions but are available from the corresponding author for researchers meeting criteria for access to confidential data. This is an acceptable data availability statement for clinical datasets containing potentially identifiable patient information.

4.The manuscript is well-presented, logically structured (abstract, introduction, methods, results, discussion), and written in clear, standard English.

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Reviewer #1: No

Reviewer #2: Yes: Zheng Xu

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Adoption and validation of the European Association for the Study of the Liver algorithm for the noninvasive diagnosis of advanced fibrosis in metabolic dysfunction-associated steatotic liver disease in low-resource South Asian settings.

PONE-D-25-61395R1

Dear Dr. Mettananda,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Sophia Eugenia Martínez-Vázquez, Ph.D.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Dear Authors,

Thank you for the reception and settings you made. I consider the manuscript is ready. Congratulations.

Reviewers' comments: