We thank Dr. Yilmaz et al. for comments on our article.1 The results of the pilot study Yilmaz and colleagues conducted in patients with nonalcoholic fatty liver disease (NAFLD) and normal alanine aminotransferase (ALT) levels confirm our finding that the severity of insulin resistance is an independent predictor of liver damage in these patients, and suggest that serum levels of M30, a neoepitope of cytokeratin 18 (CK-18) released during the early phases of apoptosis, may prove useful to discriminate patients with nonalcoholic steatohepatitis (NASH) from those with simple steatosis. There is growing interest in evaluating apoptosis markers as potential predictors of liver damage in NAFLD, and preliminary studies in patients with increased ALT levels have provided encouraging results.2 Recent data showed that cytokeratin CK-18 (M65 antigen) and caspase-cleaved CK-18 (M30 antigen), two soluble forms of extracellular cytokeratin 18, have both a good sensitivity and specificity, with M65 having a higher predictive value to diagnose NASH.3 Larger prospective cooperative studies are needed to test the performance of these new apoptosis markers in discriminating patients with NASH and potentially progressive liver disease from those with benign disease, even before severe fibrosis ensues, and to compare these tests with other noninvasive risk scores.4 Based on the present results, and the preliminary data reported by Yilmaz, we think that future research should evaluate the combined role of genetic, apoptotic, and serological markers of insulin resistance in the noninvasive diagnosis of NASH including patients with or without increased ALT. Anna Ludovica Fracanzani*, Luca Valenti*, Silvia Fargion*, * Dipartimento Medicina Interna, Centro Studio Ecura Malattie Meta Boliche, Fondazione IRCCS Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy.
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