Title: Predictive Role of the Albumin-Bilirubin Score in ICU Patients with Cirrhosis and Sepsis:
Insights from a Large Retrospective Cohort
Version: 0 Date: 30 Apr 2025
Reviewer:  Iliana Mani
Reviewer's report:
This is an interesting study examining prognostic significance of ALBI score in cirrhotic patients
with sepsis. Although of clinical interest, there are several limitations in in its current form.
Major comments:
• Liver failure should be diagnosed based on well-established criteria like EASL or APASL. The
definition provided in supplementary material is rather general, making diagnosis questionable
(“Elevated Liver Enzymes: Significant increases in serum alanine aminotransferase (ALT)
and aspartate aminotransferase (AST), indicating liver cell damage. Elevated Bilirubin Levels:
Serum bilirubin levels above the normal reference range, which is a direct marker of impaired
liver excretion. Hypoalbuminemia: Low serum albumin levels, reflecting the liver ’ s reduced
synthetic capacity”
• The incidence of fungal infections is much higher than that reported in the literature.
[Fernández J, Piano S, Bartoletti M, Wey EQ. Management of bacterial and fungal infections
in cirrhosis: The MDRO challenge. J Hepatol. 2021 Jul;75 Suppl 1:S101-S117. doi: 10.1016/
j.jhep.2020.11.010]. Which criteria were applied for the diagnosis of fungal infections?
• Multivariate analysis-model 3. Authors used as covariates paltelets and creatinine but also
SOFA score. The above parametres are parts of the SOFA score. Inclusion of highly correlated
variables in multivariate analysis leads to multicollinearity problems making interpretation of
results problematic.
• To further support the statement that ALBI is a usefull prognostic tool in cirrhotic patients wih
sepsis, authors should compare its prognostic accuracy to this of other well-established markers,
like MELD, ACLF-score, SOFA score. ROC curves should be provided and compared for the
above parameters.
• Lack of a validation cohort should be added in study limitations.
Minor comments:
• Page 8, line 78: Instead of “liver-related diseases” authors could use “complications”
• Table 1 and Supplementary table 1:
- Liver failure, encephalopathy, ascites and variceal bleeding should be categorized separately
as there are complications of liver disease and not comorbidities.
Title: Predictive Role of the Albumin-Bilirubin Score in ICU Patients with Cirrhosis and Sepsis:
Insights from a Large Retrospective Cohort
Version: 0 Date: 30 Apr 2025
Reviewer:  Iliana Mani
Reviewer's report:
This is an interesting study examining prognostic significance of ALBI score in cirrhotic patients
with sepsis. Although of clinical interest, there are several limitations in in its current form.
Major comments:
• Liver failure should be diagnosed based on well-established criteria like EASL or APASL. The
definition provided in supplementary material is rather general, making diagnosis questionable
(“Elevated Liver Enzymes: Significant increases in serum alanine aminotransferase (ALT)
and aspartate aminotransferase (AST), indicating liver cell damage. Elevated Bilirubin Levels:
Serum bilirubin levels above the normal reference range, which is a direct marker of impaired
liver excretion. Hypoalbuminemia: Low serum albumin levels, reflecting the liver ’ s reduced
synthetic capacity”
• The incidence of fungal infections is much higher than that reported in the literature.
[Fernández J, Piano S, Bartoletti M, Wey EQ. Management of bacterial and fungal infections
in cirrhosis: The MDRO challenge. J Hepatol. 2021 Jul;75 Suppl 1:S101-S117. doi: 10.1016/
j.jhep.2020.11.010]. Which criteria were applied for the diagnosis of fungal infections?
• Multivariate analysis-model 3. Authors used as covariates paltelets and creatinine but also
SOFA score. The above parametres are parts of the SOFA score. Inclusion of highly correlated
variables in multivariate analysis leads to multicollinearity problems making interpretation of
results problematic.
• To further support the statement that ALBI is a usefull prognostic tool in cirrhotic patients wih
sepsis, authors should compare its prognostic accuracy to this of other well-established markers,
like MELD, ACLF-score, SOFA score. ROC curves should be provided and compared for the
above parameters.
• Lack of a validation cohort should be added in study limitations.
Minor comments:
• Page 8, line 78: Instead of “liver-related diseases” authors could use “complications”
• Table 1 and Supplementary table 1:
- Liver failure, encephalopathy, ascites and variceal bleeding should be categorized separately
as there are complications of liver disease and not comorbidities.
Please review this paper.
user
Title: Predictive Role of the Albumin-Bilirubin Score in ICU Patients with Cirrhosis and Sepsis:
Insights from a Large Retrospective Cohort
Version: 0 Date: 30 Apr 2025
Reviewer:  Iliana Mani
Reviewer's report:
This is an interesting study examining prognostic significance of ALBI score in cirrhotic patients
with sepsis. Although of clinical interest, there are several limitations in in its current form.
Major comments:
• Liver failure should be diagnosed based on well-established criteria like EASL or APASL. The
definition provided in supplementary material is rather general, making diagnosis questionable
(“Elevated Liver Enzymes: Significant increases in serum alanine aminotransferase (ALT)
and aspartate aminotransferase (AST), indicating liver cell damage. Elevated Bilirubin Levels:
Serum bilirubin levels above the normal reference range, which is a direct marker of impaired
liver excretion. Hypoalbuminemia: Low serum albumin levels, reflecting the liver ’ s reduced
synthetic capacity”
• The incidence of fungal infections is much higher than that reported in the literature.
[Fernández J, Piano S, Bartoletti M, Wey EQ. Management of bacterial and fungal infections
in cirrhosis: The MDRO challenge. J Hepatol. 2021 Jul;75 Suppl 1:S101-S117. doi: 10.1016/
j.jhep.2020.11.010]. Which criteria were applied for the diagnosis of fungal infections?
• Multivariate analysis-model 3. Authors used as covariates paltelets and creatinine but also
SOFA score. The above parametres are parts of the SOFA score. Inclusion of highly correlated
variables in multivariate analysis leads to multicollinearity problems making interpretation of
results problematic.
• To further support the statement that ALBI is a usefull prognostic tool in cirrhotic patients wih
sepsis, authors should compare its prognostic accuracy to this of other well-established markers,
like MELD, ACLF-score, SOFA score. ROC curves should be provided and compared for the
above parameters.
• Lack of a validation cohort should be added in study limitations.
Minor comments:
• Page 8, line 78: Instead of “liver-related diseases” authors could use “complications”
• Table 1 and Supplementary table 1:
- Liver failure, encephalopathy, ascites and variceal bleeding should be categorized separately
as there are complications of liver disease and not comorbidities.
assistant