Title: Consensus Care Recommendations for alfapump ® in Cirrhotic Patients with Refractory
or Recurrent Ascites
Version: 3 Date: 04 Dec 2021
Reviewer's report:
Aagaard et al describe a consensus statement on ALFA pump for management of refractory
ascites. There are clearly some patients with refractory ascites who will be suitable for this
procedure and so the manuscript is a useful addition to the medical literature. My comments
are below
1. Concerns remain about the high risk of adverse events, also confirmed by a recent sys
review (Lepido et al APT 2019). The authors need to address the main adverse events (and
management)  of the alfapump (maybe  in a table) so that readers are aware. There is an ongoing
trial (POSEIDIN)(again not mentioned by the authors) which I am assuming is using new
peritoneal catheter which may reduce risk of adverse events
2. The alfa pump is not routinely available at least in the UK and has undergone NICE
assessment which recommends use only in research setting .  “Current evidence on the safety
of subcutaneous automated low-flow pump implantation for refractory ascites shows there are
serious but well-recognised safety concerns, including device failure and acute kidney injury.
Evidence on efficacy is limited in quantity. Therefore, this procedure should only be used with
special arrangements for clinical governance, consent, and audit or research [IPG631]. I do not
have a sense if the same applies to other European Countries. This  issue of alfa pump availability
needs to be clearly addressed by the authors
3. The alfa pump is expensive ? 30K and this could be considered prohibitive in some healthcare
systems. Again not addressed by authors
4. Need more clarification on indication for long-term human albumin solution in those with
an alfa pump in situ
5. Is there any role of the alfa pump as a palliative intervention ?
6. The authors mention both the EASL and AASLD ascites guidelines re NSBB and refractory
ascites but make no mention of the recently published UK Ascites guidelines (Aithal GP, Gut
2021) which state until randomised high quality data is available, the current evidence base
supports the use of NSBBB when indicated in patients with refractory ascites unless alternative
markers of circulatory failure such as hypotension or reduced glomerular filtration rate are
present.
7. No references were provided
Title: Consensus Care Recommendations for alfapump ® in Cirrhotic Patients with Refractory
or Recurrent Ascites
Version: 3 Date: 04 Dec 2021
Reviewer's report:
Aagaard et al describe a consensus statement on ALFA pump for management of refractory
ascites. There are clearly some patients with refractory ascites who will be suitable for this
procedure and so the manuscript is a useful addition to the medical literature. My comments
are below
1. Concerns remain about the high risk of adverse events, also confirmed by a recent sys
review (Lepido et al APT 2019). The authors need to address the main adverse events (and
management)  of the alfapump (maybe  in a table) so that readers are aware. There is an ongoing
trial (POSEIDIN)(again not mentioned by the authors) which I am assuming is using new
peritoneal catheter which may reduce risk of adverse events
2. The alfa pump is not routinely available at least in the UK and has undergone NICE
assessment which recommends use only in research setting .  “Current evidence on the safety
of subcutaneous automated low-flow pump implantation for refractory ascites shows there are
serious but well-recognised safety concerns, including device failure and acute kidney injury.
Evidence on efficacy is limited in quantity. Therefore, this procedure should only be used with
special arrangements for clinical governance, consent, and audit or research [IPG631]. I do not
have a sense if the same applies to other European Countries. This  issue of alfa pump availability
needs to be clearly addressed by the authors
3. The alfa pump is expensive ? 30K and this could be considered prohibitive in some healthcare
systems. Again not addressed by authors
4. Need more clarification on indication for long-term human albumin solution in those with
an alfa pump in situ
5. Is there any role of the alfa pump as a palliative intervention ?
6. The authors mention both the EASL and AASLD ascites guidelines re NSBB and refractory
ascites but make no mention of the recently published UK Ascites guidelines (Aithal GP, Gut
2021) which state until randomised high quality data is available, the current evidence base
supports the use of NSBBB when indicated in patients with refractory ascites unless alternative
markers of circulatory failure such as hypotension or reduced glomerular filtration rate are
present.
7. No references were provided
Please review this paper.
user
Title: Consensus Care Recommendations for alfapump ® in Cirrhotic Patients with Refractory
or Recurrent Ascites
Version: 3 Date: 04 Dec 2021
Reviewer's report:
Aagaard et al describe a consensus statement on ALFA pump for management of refractory
ascites. There are clearly some patients with refractory ascites who will be suitable for this
procedure and so the manuscript is a useful addition to the medical literature. My comments
are below
1. Concerns remain about the high risk of adverse events, also confirmed by a recent sys
review (Lepido et al APT 2019). The authors need to address the main adverse events (and
management)  of the alfapump (maybe  in a table) so that readers are aware. There is an ongoing
trial (POSEIDIN)(again not mentioned by the authors) which I am assuming is using new
peritoneal catheter which may reduce risk of adverse events
2. The alfa pump is not routinely available at least in the UK and has undergone NICE
assessment which recommends use only in research setting .  “Current evidence on the safety
of subcutaneous automated low-flow pump implantation for refractory ascites shows there are
serious but well-recognised safety concerns, including device failure and acute kidney injury.
Evidence on efficacy is limited in quantity. Therefore, this procedure should only be used with
special arrangements for clinical governance, consent, and audit or research [IPG631]. I do not
have a sense if the same applies to other European Countries. This  issue of alfa pump availability
needs to be clearly addressed by the authors
3. The alfa pump is expensive ? 30K and this could be considered prohibitive in some healthcare
systems. Again not addressed by authors
4. Need more clarification on indication for long-term human albumin solution in those with
an alfa pump in situ
5. Is there any role of the alfa pump as a palliative intervention ?
6. The authors mention both the EASL and AASLD ascites guidelines re NSBB and refractory
ascites but make no mention of the recently published UK Ascites guidelines (Aithal GP, Gut
2021) which state until randomised high quality data is available, the current evidence base
supports the use of NSBBB when indicated in patients with refractory ascites unless alternative
markers of circulatory failure such as hypotension or reduced glomerular filtration rate are
present.
7. No references were provided
assistant