Reviewer ’s report  
 
Title: The incidence, etiolog ies, outcomes, and predictors of mort ality of acute liver failure in 
Thailand: a population -base study  
 
Version: 0 Date: 12 Nov 2018  
 
Revie wer: Zhou Zhou  
 
Reviewer's report:  
 
The present study discussed the statistical features of acute liver failure in clinical practice of 
Thailand. Here are some major concerns:  
 
 
1. The authors collected the data between 2009 and 2013. Why would the authors select the 
data in this  period? Is there any specific reason of this period? The authors need to 
provide a reason and discuss the possible changes in the current years.  
 
 
2. Why are indeterminate cases of ALF so prevalent in the present study? Without knowing 
the nature of more t han 50% of the cases studied in the current report, the conclusions 
may be skewed or incorrect. Cases selected in the current study may be drastically 
influenced by other factors. The authors need to provide the reason and justification that 
the conclusion s will be solid.   
 
 
3. Although mechanic ventilation support shows the most significant difference between the 
survived and non -survived patients within 30 days treatment, it should not be considered 
as predictive factor because it is not useful or even misleading to clinical  practitioners. As 
the last resort of treatment, ventilator can be easily correlated to high fatality in any 
disease. However, it is not a useful indicator of fatality and the clinicians should not 
reduce its usage for treatment. Similarly, length of hospi tal stay and renal dialysis are not 
supposed to be a predictive factor either.  
 
 
4. There is a lot of contradictory information in the current study. In table 1, male gender, 
COPD, Hepatitis B, Hepatitis C, non -acetaminophen drugs, vascular cause and urinary  
tract infection are extremely significant factors. However, they are not at all significant in 
Table 3. The authors need to explain the reason.  
 
 
5. In Table 3, acetaminophen is extremely significant and the adjusted hazardous ratio is 
below 1. The authors  need to explain this result and clarify acetaminophen is not 
protective to ALF.  
 
6. In discussion, the authors compared the 30 day fatality rate in Thailand and United 
States/United Kingdom. Even though the authors did not jump to any conclusion, the 
authors should not put them side by side simply like this. The authors need to define the 
difference of population, medical care, special medical background of the patients, and 
especially the years when data were collected.  
 
 
7. If available, the authors shoul d add and analyze other regular treatment methods to the 
current study, including antibiotic usage, virus management, bleeding control, 
detoxification, cerebral edema control, etc.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quali ty of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received rei mbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or  lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary fr om an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no  to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publicati on, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my name d report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: The incidence, etiolog ies, outcomes, and predictors of mort ality of acute liver failure in 
Thailand: a population -base study  
 
Version: 0 Date: 12 Nov 2018  
 
Revie wer: Zhou Zhou  
 
Reviewer's report:  
 
The present study discussed the statistical features of acute liver failure in clinical practice of 
Thailand. Here are some major concerns:  
 
 
1. The authors collected the data between 2009 and 2013. Why would the authors select the 
data in this  period? Is there any specific reason of this period? The authors need to 
provide a reason and discuss the possible changes in the current years.  
 
 
2. Why are indeterminate cases of ALF so prevalent in the present study? Without knowing 
the nature of more t han 50% of the cases studied in the current report, the conclusions 
may be skewed or incorrect. Cases selected in the current study may be drastically 
influenced by other factors. The authors need to provide the reason and justification that 
the conclusion s will be solid.   
 
 
3. Although mechanic ventilation support shows the most significant difference between the 
survived and non -survived patients within 30 days treatment, it should not be considered 
as predictive factor because it is not useful or even misleading to clinical  practitioners. As 
the last resort of treatment, ventilator can be easily correlated to high fatality in any 
disease. However, it is not a useful indicator of fatality and the clinicians should not 
reduce its usage for treatment. Similarly, length of hospi tal stay and renal dialysis are not 
supposed to be a predictive factor either.  
 
 
4. There is a lot of contradictory information in the current study. In table 1, male gender, 
COPD, Hepatitis B, Hepatitis C, non -acetaminophen drugs, vascular cause and urinary  
tract infection are extremely significant factors. However, they are not at all significant in 
Table 3. The authors need to explain the reason.  
 
 
5. In Table 3, acetaminophen is extremely significant and the adjusted hazardous ratio is 
below 1. The authors  need to explain this result and clarify acetaminophen is not 
protective to ALF.  
 
6. In discussion, the authors compared the 30 day fatality rate in Thailand and United 
States/United Kingdom. Even though the authors did not jump to any conclusion, the 
authors should not put them side by side simply like this. The authors need to define the 
difference of population, medical care, special medical background of the patients, and 
especially the years when data were collected.  
 
 
7. If available, the authors shoul d add and analyze other regular treatment methods to the 
current study, including antibiotic usage, virus management, bleeding control, 
detoxification, cerebral edema control, etc.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quali ty of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received rei mbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or  lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary fr om an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no  to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publicati on, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my name d report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: The incidence, etiolog ies, outcomes, and predictors of mort ality of acute liver failure in 
Thailand: a population -base study  
 
Version: 0 Date: 12 Nov 2018  
 
Revie wer: Zhou Zhou  
 
Reviewer's report:  
 
The present study discussed the statistical features of acute liver failure in clinical practice of 
Thailand. Here are some major concerns:  
 
 
1. The authors collected the data between 2009 and 2013. Why would the authors select the 
data in this  period? Is there any specific reason of this period? The authors need to 
provide a reason and discuss the possible changes in the current years.  
 
 
2. Why are indeterminate cases of ALF so prevalent in the present study? Without knowing 
the nature of more t han 50% of the cases studied in the current report, the conclusions 
may be skewed or incorrect. Cases selected in the current study may be drastically 
influenced by other factors. The authors need to provide the reason and justification that 
the conclusion s will be solid.   
 
 
3. Although mechanic ventilation support shows the most significant difference between the 
survived and non -survived patients within 30 days treatment, it should not be considered 
as predictive factor because it is not useful or even misleading to clinical  practitioners. As 
the last resort of treatment, ventilator can be easily correlated to high fatality in any 
disease. However, it is not a useful indicator of fatality and the clinicians should not 
reduce its usage for treatment. Similarly, length of hospi tal stay and renal dialysis are not 
supposed to be a predictive factor either.  
 
 
4. There is a lot of contradictory information in the current study. In table 1, male gender, 
COPD, Hepatitis B, Hepatitis C, non -acetaminophen drugs, vascular cause and urinary  
tract infection are extremely significant factors. However, they are not at all significant in 
Table 3. The authors need to explain the reason.  
 
 
5. In Table 3, acetaminophen is extremely significant and the adjusted hazardous ratio is 
below 1. The authors  need to explain this result and clarify acetaminophen is not 
protective to ALF.  
 
6. In discussion, the authors compared the 30 day fatality rate in Thailand and United 
States/United Kingdom. Even though the authors did not jump to any conclusion, the 
authors should not put them side by side simply like this. The authors need to define the 
difference of population, medical care, special medical background of the patients, and 
especially the years when data were collected.  
 
 
7. If available, the authors shoul d add and analyze other regular treatment methods to the 
current study, including antibiotic usage, virus management, bleeding control, 
detoxification, cerebral edema control, etc.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quali ty of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received rei mbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or  lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary fr om an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no  to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publicati on, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my name d report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant