Title: Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse
specialists using the ELF test
Version: 2 Date: 30 Dec 2020
Reviewer's report:
The study by Rhodes et al. aims at investigating prevalence and predictors of advanced fibrosis
assessed by ELF in a cohort of alcoholic patients.
The study is really well conducted and the topic of highly clinical and public relevance. Some
minor points need to be addressed.
- Given the lack of association between fibrosis and both amount of alcohol consumption
and drinking duration, a bias related to the self-reported information about drinking could be
supposed? I suggest that the Authors should make a comment about this possibile bias in the
discussion and also mention the lack of AUDIT about drinking in the limitations. Was data about
desialated transferrin (CDT) available?
- Since type 2 diabetes (T2DM) has been demonstrated as one of the most important fibrogenic
factors, was the information about diabetes status available? If yes please add T2DM in the
analysis, otherwise I suggest that the Authors sould add also this missing information in the
limitations.
- In the outcomes it is stated that "Blood samples were also taken to screen for viral,
immunological and metabolic causes of liver disease if these tests had been omitted during their
hospital admission. ", but it is not clear if bloods were repeated if the information about screening
was not available at the moment of ELF calculation (i.e if referring to 2 years before was valid
because available?). Please clarify.
- How do the Authors explain the lack of association between ELF and FIB4 (predictive both
of advanced fibrosis?).
- Why did the Authors choose to adjust analysis for ALP and not for GGT as the patients are
active drinkers?
- In the discussion it is stated that "Whilst it has previously been reported that ELF scores may
be influenced by inflammation (16, 21), we did not find any correlation between ELF score
and ALT or AST, as markers of hepatic inflammation in this study, suggesting ELF was not
influenced by inflammation in our cohort". Given the fact that transaminases not always reflect
hepatic inflammation possibily underestimating liver damage and that histology is missing, this
sentence should be smoothed.
- Finally, in the follow-up and in the discussion, there is a hint to Fibroscan, however no data
or results referring to fibroscan stiffness could be found anywhere. In particular, it could be
interesting to know how many patients diagnosed with advanced fibrosis by ELF were confirmed
by Fibroscan.
Title: Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse
specialists using the ELF test
Version: 2 Date: 30 Dec 2020
Reviewer's report:
The study by Rhodes et al. aims at investigating prevalence and predictors of advanced fibrosis
assessed by ELF in a cohort of alcoholic patients.
The study is really well conducted and the topic of highly clinical and public relevance. Some
minor points need to be addressed.
- Given the lack of association between fibrosis and both amount of alcohol consumption
and drinking duration, a bias related to the self-reported information about drinking could be
supposed? I suggest that the Authors should make a comment about this possibile bias in the
discussion and also mention the lack of AUDIT about drinking in the limitations. Was data about
desialated transferrin (CDT) available?
- Since type 2 diabetes (T2DM) has been demonstrated as one of the most important fibrogenic
factors, was the information about diabetes status available? If yes please add T2DM in the
analysis, otherwise I suggest that the Authors sould add also this missing information in the
limitations.
- In the outcomes it is stated that "Blood samples were also taken to screen for viral,
immunological and metabolic causes of liver disease if these tests had been omitted during their
hospital admission. ", but it is not clear if bloods were repeated if the information about screening
was not available at the moment of ELF calculation (i.e if referring to 2 years before was valid
because available?). Please clarify.
- How do the Authors explain the lack of association between ELF and FIB4 (predictive both
of advanced fibrosis?).
- Why did the Authors choose to adjust analysis for ALP and not for GGT as the patients are
active drinkers?
- In the discussion it is stated that "Whilst it has previously been reported that ELF scores may
be influenced by inflammation (16, 21), we did not find any correlation between ELF score
and ALT or AST, as markers of hepatic inflammation in this study, suggesting ELF was not
influenced by inflammation in our cohort". Given the fact that transaminases not always reflect
hepatic inflammation possibily underestimating liver damage and that histology is missing, this
sentence should be smoothed.
- Finally, in the follow-up and in the discussion, there is a hint to Fibroscan, however no data
or results referring to fibroscan stiffness could be found anywhere. In particular, it could be
interesting to know how many patients diagnosed with advanced fibrosis by ELF were confirmed
by Fibroscan.
Please review this paper.
user
Title: Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse
specialists using the ELF test
Version: 2 Date: 30 Dec 2020
Reviewer's report:
The study by Rhodes et al. aims at investigating prevalence and predictors of advanced fibrosis
assessed by ELF in a cohort of alcoholic patients.
The study is really well conducted and the topic of highly clinical and public relevance. Some
minor points need to be addressed.
- Given the lack of association between fibrosis and both amount of alcohol consumption
and drinking duration, a bias related to the self-reported information about drinking could be
supposed? I suggest that the Authors should make a comment about this possibile bias in the
discussion and also mention the lack of AUDIT about drinking in the limitations. Was data about
desialated transferrin (CDT) available?
- Since type 2 diabetes (T2DM) has been demonstrated as one of the most important fibrogenic
factors, was the information about diabetes status available? If yes please add T2DM in the
analysis, otherwise I suggest that the Authors sould add also this missing information in the
limitations.
- In the outcomes it is stated that "Blood samples were also taken to screen for viral,
immunological and metabolic causes of liver disease if these tests had been omitted during their
hospital admission. ", but it is not clear if bloods were repeated if the information about screening
was not available at the moment of ELF calculation (i.e if referring to 2 years before was valid
because available?). Please clarify.
- How do the Authors explain the lack of association between ELF and FIB4 (predictive both
of advanced fibrosis?).
- Why did the Authors choose to adjust analysis for ALP and not for GGT as the patients are
active drinkers?
- In the discussion it is stated that "Whilst it has previously been reported that ELF scores may
be influenced by inflammation (16, 21), we did not find any correlation between ELF score
and ALT or AST, as markers of hepatic inflammation in this study, suggesting ELF was not
influenced by inflammation in our cohort". Given the fact that transaminases not always reflect
hepatic inflammation possibily underestimating liver damage and that histology is missing, this
sentence should be smoothed.
- Finally, in the follow-up and in the discussion, there is a hint to Fibroscan, however no data
or results referring to fibroscan stiffness could be found anywhere. In particular, it could be
interesting to know how many patients diagnosed with advanced fibrosis by ELF were confirmed
by Fibroscan.
assistant