Title: Effect of plasma adsorption and low-volume plasma exchange on intracranial pressure in
acute-on-chronic liver failure: A prospective observational study
Version: 2 Date: 02 Jun 2025
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
No - there are major issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are major issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The authors responded well to the comments. However, the main
problem  fthe study is that none of the enrolled patients exhibited elevated ICP at baseline. As
such, the cohort lacked the very pathological condition the intervention was intended to address.
Consequently, the findings are essentially negative with respect to the primary hypothesis, and
the study does not provide meaningful evidence regarding the efficacy of these treatments in
reducing elevated ICP in ACLF.
REQUESTED REVISIONS:
A key limitation of this study lies in the fact that none of the included patients had elevated
intracranial pressure (ICP) at baseline—effectively rendering the central hypothesis untestable
within this cohort. Ideally, the presence of elevated ICP should have been an essential inclusion
criterion. However, it is understandable that current clinical constraints may make such pre-
selection difficult or even unfeasible.
Moreover, the study would have benefited from the inclusion of liver function parameters before
and after ALSS treatment. Presenting such data, ideally with comparative analysis, would allow
for a more comprehensive assessment of the intervention’s efficacy. If improvements in liver
function were observed, the authors could then more meaningfully discuss the safety profile of
ALSS with respect to ICP, even in the absence of intracranial hypertension.
Title: Effect of plasma adsorption and low-volume plasma exchange on intracranial pressure in
acute-on-chronic liver failure: A prospective observational study
Version: 2 Date: 02 Jun 2025
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
No - there are major issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are major issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The authors responded well to the comments. However, the main
problem  fthe study is that none of the enrolled patients exhibited elevated ICP at baseline. As
such, the cohort lacked the very pathological condition the intervention was intended to address.
Consequently, the findings are essentially negative with respect to the primary hypothesis, and
the study does not provide meaningful evidence regarding the efficacy of these treatments in
reducing elevated ICP in ACLF.
REQUESTED REVISIONS:
A key limitation of this study lies in the fact that none of the included patients had elevated
intracranial pressure (ICP) at baseline—effectively rendering the central hypothesis untestable
within this cohort. Ideally, the presence of elevated ICP should have been an essential inclusion
criterion. However, it is understandable that current clinical constraints may make such pre-
selection difficult or even unfeasible.
Moreover, the study would have benefited from the inclusion of liver function parameters before
and after ALSS treatment. Presenting such data, ideally with comparative analysis, would allow
for a more comprehensive assessment of the intervention’s efficacy. If improvements in liver
function were observed, the authors could then more meaningfully discuss the safety profile of
ALSS with respect to ICP, even in the absence of intracranial hypertension.
Please review this paper.
user
Title: Effect of plasma adsorption and low-volume plasma exchange on intracranial pressure in
acute-on-chronic liver failure: A prospective observational study
Version: 2 Date: 02 Jun 2025
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
No - there are major issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are major issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The authors responded well to the comments. However, the main
problem  fthe study is that none of the enrolled patients exhibited elevated ICP at baseline. As
such, the cohort lacked the very pathological condition the intervention was intended to address.
Consequently, the findings are essentially negative with respect to the primary hypothesis, and
the study does not provide meaningful evidence regarding the efficacy of these treatments in
reducing elevated ICP in ACLF.
REQUESTED REVISIONS:
A key limitation of this study lies in the fact that none of the included patients had elevated
intracranial pressure (ICP) at baseline—effectively rendering the central hypothesis untestable
within this cohort. Ideally, the presence of elevated ICP should have been an essential inclusion
criterion. However, it is understandable that current clinical constraints may make such pre-
selection difficult or even unfeasible.
Moreover, the study would have benefited from the inclusion of liver function parameters before
and after ALSS treatment. Presenting such data, ideally with comparative analysis, would allow
for a more comprehensive assessment of the intervention’s efficacy. If improvements in liver
function were observed, the authors could then more meaningfully discuss the safety profile of
ALSS with respect to ICP, even in the absence of intracranial hypertension.
assistant