Title: Association of Thromboelastography Profile with Severity of Liver Cirrhosis and Portal
Venous System Thrombosis
Version: 2 Date: 15 Apr 2021
Reviewer:  Iliana Mani
Reviewer's report:
The utility of thromboelastography in the management of cirrhosis and its complications is
increasingly being studied. The results of the present study are intriguing and could inspire
further research in this field. In my opinion, the design of the study, the presentation of the main
results and the core idea are acceptable for publication. However, the manuscript needs further
editing.
Page 1, line 16.
The statement “These authors are equally contributed” should be replaced by  “These authors
contributed equally”.
Page 4, lines 76-77.
Please rephrase “By comparison, thromboelastography (TEG), a novel global viscoelastic test,
has been increasingly recognized. ”
Page 4, lines 77-78.
Instead of “The current guideline and consensus have recommended that TEG can evaluate
the status of hemostasis more comprehensively” authors could write “The current guidelines
and consensus recommended that or stated or proposed that TEG could evaluate the status of
hemostasis more comprehensively”.
Page 5, line 94.
Instead of “patients who received the drugs influencing coagulation status” authors should write
“patients who received drugs with documented impact on coagulation status”.
Page 5, lines 104-105
Instead of “The TEG profile in the Shenyang cohort was detected” authors could write “The
TEG profile in the Shenyang cohort was accessed or studied”
Page 5, lines 106-109
Authors should use the past tense in the entire paragraph.
Page 6, line 115
Instead of “ …on the clinical, laboratory, and radiological examinations,” authors could write
“on clinical, laboratory, and radiological examinations”
Page 11, line 223
Instead of “ … in cirrhosis was shown in,” authors should write “in cirrhosis is shown in”
Page 11, line 228.
Page 11, lines 228-232.
Authors stated that “ Patients with liver cirrhosis are often at a bleeding risk, because they are
traditionally considered to have a hypocoagulation status indicated by CCTs, such as prolonged
PT and activated partial thromboplastin time. However, recent evidence has suggested that
elevated INR should be unrelated to a higher risk of bleeding in liver cirrhosis[12-14] and that
global hemostatic status indicated by thrombin generation assay in liver cirrhosis should be
relatively normal[2, 4, 5] ”
In my opinion this paragraph should be rephrased in order to become more understandable.
For example: “Patients with cirrhosis are often considered to be at risk for bleeding because of
deteriorated or abnormal CCTs. ” “ Recent evidence demonstrated that elevated INR was not
indicative of a higher risk for bleeding, as in such patients, the hemostatic status, accessed by
thrombin generation assays was rather normal”
Page 11, line 235.
Please rephrase “TEG can globally detect the functions, amounts, and interactions of pro-
coagulants, anti-coagulants, PLT, and cells.”
Page11, line 241
Instead of “ … trend of hypocoagulability” authors could write “trend for hypocoagulability”
Page 12, lines 257-258.
Please rephrase “ found that hypercoagulation indicated by higher MA was associated with
PVST in cirrhosis with hepatocellular carcinoma. However, cancer itself could also trigger
hypercoagulation. Therefore, the Zanetto’s findings could not be extrapolated to the association
between TEG profile and PVST in non-malignant liver cirrhosis”
Page 12, line 262
Please rephrase “Their eligible patients were restricted to the presence of gastroesophageal
varices alone, while our study population did not limit the complications or severity of liver
cirrhosis.”
Page 12, line 264
Instead of “our study did not find any significant difference of median R and proportion of
shortened R between cirrhotic patients with and without PVST.” authors could write “we did
not find any significant difference in median R or proportion of shortened R between cirrhotic
patients with and without PVST.”
Page 13, lines 265-268
Please rephrase “also suggested that hypercoagulability indicated by TEG profile should not be
an important contributor to PVST formation in cirrhosis, which is similar to the results of our
previous meta-analysis that antithrombin, protein C, and protein S levels were not significantly
different between patients with and without PVST after matching Child-Pugh class. Indeed, the
formation of PVST is multifactorial in liver cirrhosis”
Page 13, lines 270-273
Please rephrase “A decreased portal vein velocity should be considered as the most important
risk factor for PVST formation after adjusting thrombotic risk factors, such as antithrombin,
protein C, lupus anticoagulant, cryoglobulins, and hyper-homocysteine”
Page 13, lines 277-279
Please rephrase “First, TEG facilities and reference ranges of TEG parameters are different at
the two centers, but their reagents used (citrated kaolin) and technical principles are the same
between them.”
Page 13, line 280
Please rephrase “…resulting in the heterogeneity of TEG values obtained from the two cohorts“,
authors could write “… a parameter that it is possible to contribute to the heterogeneity of TEG
values obtained from the two cohorts”.
Page 13, line 282
Instead of “we did not detect the levels… “, authors could write “…we did not measured levels
of…”.
Title: Association of Thromboelastography Profile with Severity of Liver Cirrhosis and Portal
Venous System Thrombosis
Version: 2 Date: 15 Apr 2021
Reviewer:  Iliana Mani
Reviewer's report:
The utility of thromboelastography in the management of cirrhosis and its complications is
increasingly being studied. The results of the present study are intriguing and could inspire
further research in this field. In my opinion, the design of the study, the presentation of the main
results and the core idea are acceptable for publication. However, the manuscript needs further
editing.
Page 1, line 16.
The statement “These authors are equally contributed” should be replaced by  “These authors
contributed equally”.
Page 4, lines 76-77.
Please rephrase “By comparison, thromboelastography (TEG), a novel global viscoelastic test,
has been increasingly recognized. ”
Page 4, lines 77-78.
Instead of “The current guideline and consensus have recommended that TEG can evaluate
the status of hemostasis more comprehensively” authors could write “The current guidelines
and consensus recommended that or stated or proposed that TEG could evaluate the status of
hemostasis more comprehensively”.
Page 5, line 94.
Instead of “patients who received the drugs influencing coagulation status” authors should write
“patients who received drugs with documented impact on coagulation status”.
Page 5, lines 104-105
Instead of “The TEG profile in the Shenyang cohort was detected” authors could write “The
TEG profile in the Shenyang cohort was accessed or studied”
Page 5, lines 106-109
Authors should use the past tense in the entire paragraph.
Page 6, line 115
Instead of “ …on the clinical, laboratory, and radiological examinations,” authors could write
“on clinical, laboratory, and radiological examinations”
Page 11, line 223
Instead of “ … in cirrhosis was shown in,” authors should write “in cirrhosis is shown in”
Page 11, line 228.
Page 11, lines 228-232.
Authors stated that “ Patients with liver cirrhosis are often at a bleeding risk, because they are
traditionally considered to have a hypocoagulation status indicated by CCTs, such as prolonged
PT and activated partial thromboplastin time. However, recent evidence has suggested that
elevated INR should be unrelated to a higher risk of bleeding in liver cirrhosis[12-14] and that
global hemostatic status indicated by thrombin generation assay in liver cirrhosis should be
relatively normal[2, 4, 5] ”
In my opinion this paragraph should be rephrased in order to become more understandable.
For example: “Patients with cirrhosis are often considered to be at risk for bleeding because of
deteriorated or abnormal CCTs. ” “ Recent evidence demonstrated that elevated INR was not
indicative of a higher risk for bleeding, as in such patients, the hemostatic status, accessed by
thrombin generation assays was rather normal”
Page 11, line 235.
Please rephrase “TEG can globally detect the functions, amounts, and interactions of pro-
coagulants, anti-coagulants, PLT, and cells.”
Page11, line 241
Instead of “ … trend of hypocoagulability” authors could write “trend for hypocoagulability”
Page 12, lines 257-258.
Please rephrase “ found that hypercoagulation indicated by higher MA was associated with
PVST in cirrhosis with hepatocellular carcinoma. However, cancer itself could also trigger
hypercoagulation. Therefore, the Zanetto’s findings could not be extrapolated to the association
between TEG profile and PVST in non-malignant liver cirrhosis”
Page 12, line 262
Please rephrase “Their eligible patients were restricted to the presence of gastroesophageal
varices alone, while our study population did not limit the complications or severity of liver
cirrhosis.”
Page 12, line 264
Instead of “our study did not find any significant difference of median R and proportion of
shortened R between cirrhotic patients with and without PVST.” authors could write “we did
not find any significant difference in median R or proportion of shortened R between cirrhotic
patients with and without PVST.”
Page 13, lines 265-268
Please rephrase “also suggested that hypercoagulability indicated by TEG profile should not be
an important contributor to PVST formation in cirrhosis, which is similar to the results of our
previous meta-analysis that antithrombin, protein C, and protein S levels were not significantly
different between patients with and without PVST after matching Child-Pugh class. Indeed, the
formation of PVST is multifactorial in liver cirrhosis”
Page 13, lines 270-273
Please rephrase “A decreased portal vein velocity should be considered as the most important
risk factor for PVST formation after adjusting thrombotic risk factors, such as antithrombin,
protein C, lupus anticoagulant, cryoglobulins, and hyper-homocysteine”
Page 13, lines 277-279
Please rephrase “First, TEG facilities and reference ranges of TEG parameters are different at
the two centers, but their reagents used (citrated kaolin) and technical principles are the same
between them.”
Page 13, line 280
Please rephrase “…resulting in the heterogeneity of TEG values obtained from the two cohorts“,
authors could write “… a parameter that it is possible to contribute to the heterogeneity of TEG
values obtained from the two cohorts”.
Page 13, line 282
Instead of “we did not detect the levels… “, authors could write “…we did not measured levels
of…”.
Please review this paper.
user
Title: Association of Thromboelastography Profile with Severity of Liver Cirrhosis and Portal
Venous System Thrombosis
Version: 2 Date: 15 Apr 2021
Reviewer:  Iliana Mani
Reviewer's report:
The utility of thromboelastography in the management of cirrhosis and its complications is
increasingly being studied. The results of the present study are intriguing and could inspire
further research in this field. In my opinion, the design of the study, the presentation of the main
results and the core idea are acceptable for publication. However, the manuscript needs further
editing.
Page 1, line 16.
The statement “These authors are equally contributed” should be replaced by  “These authors
contributed equally”.
Page 4, lines 76-77.
Please rephrase “By comparison, thromboelastography (TEG), a novel global viscoelastic test,
has been increasingly recognized. ”
Page 4, lines 77-78.
Instead of “The current guideline and consensus have recommended that TEG can evaluate
the status of hemostasis more comprehensively” authors could write “The current guidelines
and consensus recommended that or stated or proposed that TEG could evaluate the status of
hemostasis more comprehensively”.
Page 5, line 94.
Instead of “patients who received the drugs influencing coagulation status” authors should write
“patients who received drugs with documented impact on coagulation status”.
Page 5, lines 104-105
Instead of “The TEG profile in the Shenyang cohort was detected” authors could write “The
TEG profile in the Shenyang cohort was accessed or studied”
Page 5, lines 106-109
Authors should use the past tense in the entire paragraph.
Page 6, line 115
Instead of “ …on the clinical, laboratory, and radiological examinations,” authors could write
“on clinical, laboratory, and radiological examinations”
Page 11, line 223
Instead of “ … in cirrhosis was shown in,” authors should write “in cirrhosis is shown in”
Page 11, line 228.
Page 11, lines 228-232.
Authors stated that “ Patients with liver cirrhosis are often at a bleeding risk, because they are
traditionally considered to have a hypocoagulation status indicated by CCTs, such as prolonged
PT and activated partial thromboplastin time. However, recent evidence has suggested that
elevated INR should be unrelated to a higher risk of bleeding in liver cirrhosis[12-14] and that
global hemostatic status indicated by thrombin generation assay in liver cirrhosis should be
relatively normal[2, 4, 5] ”
In my opinion this paragraph should be rephrased in order to become more understandable.
For example: “Patients with cirrhosis are often considered to be at risk for bleeding because of
deteriorated or abnormal CCTs. ” “ Recent evidence demonstrated that elevated INR was not
indicative of a higher risk for bleeding, as in such patients, the hemostatic status, accessed by
thrombin generation assays was rather normal”
Page 11, line 235.
Please rephrase “TEG can globally detect the functions, amounts, and interactions of pro-
coagulants, anti-coagulants, PLT, and cells.”
Page11, line 241
Instead of “ … trend of hypocoagulability” authors could write “trend for hypocoagulability”
Page 12, lines 257-258.
Please rephrase “ found that hypercoagulation indicated by higher MA was associated with
PVST in cirrhosis with hepatocellular carcinoma. However, cancer itself could also trigger
hypercoagulation. Therefore, the Zanetto’s findings could not be extrapolated to the association
between TEG profile and PVST in non-malignant liver cirrhosis”
Page 12, line 262
Please rephrase “Their eligible patients were restricted to the presence of gastroesophageal
varices alone, while our study population did not limit the complications or severity of liver
cirrhosis.”
Page 12, line 264
Instead of “our study did not find any significant difference of median R and proportion of
shortened R between cirrhotic patients with and without PVST.” authors could write “we did
not find any significant difference in median R or proportion of shortened R between cirrhotic
patients with and without PVST.”
Page 13, lines 265-268
Please rephrase “also suggested that hypercoagulability indicated by TEG profile should not be
an important contributor to PVST formation in cirrhosis, which is similar to the results of our
previous meta-analysis that antithrombin, protein C, and protein S levels were not significantly
different between patients with and without PVST after matching Child-Pugh class. Indeed, the
formation of PVST is multifactorial in liver cirrhosis”
Page 13, lines 270-273
Please rephrase “A decreased portal vein velocity should be considered as the most important
risk factor for PVST formation after adjusting thrombotic risk factors, such as antithrombin,
protein C, lupus anticoagulant, cryoglobulins, and hyper-homocysteine”
Page 13, lines 277-279
Please rephrase “First, TEG facilities and reference ranges of TEG parameters are different at
the two centers, but their reagents used (citrated kaolin) and technical principles are the same
between them.”
Page 13, line 280
Please rephrase “…resulting in the heterogeneity of TEG values obtained from the two cohorts“,
authors could write “… a parameter that it is possible to contribute to the heterogeneity of TEG
values obtained from the two cohorts”.
Page 13, line 282
Instead of “we did not detect the levels… “, authors could write “…we did not measured levels
of…”.
assistant