Reviewer's report 
 The Changes in Renal Function after a Single Dose of intravenous Furosemide in Patients with Title: 
Compensated Liver cirrhosis 
 4  20 October 2006 Version: Date: 
 Laurent Spahr Reviewer: 
Reviewer's report: 
General 
The authors have taken into consideration some comments, but I do not see the graphs with individual values of the patients. The manuscript remains difficult to read, with several spelling errors, and results (in the results section) not 
given in a logical order. Abstract : the Background section is not related to the aim and the results of the 
study. 
In particular, the authors must explain why, if they claim that DMSA uptake is a good technique to measure 
GFR, they did observe an increase only in about half of the patients with well compensated, non ascitic 
cirrhosis (in whom renal function is usually preserved). Thus, it may be suggested that the method of DMSA uptake lacks sensitivity and specificity in this setting. Regarding the accuracy of DMSA in the quantification of GFR, it is scientifically incorrect to assess that 
DMSA uptake is superior to measured or calculated creatinine clearance without comparing it with the gold 
standard (that is inulin clearance) in the same patients. 
The characteristics of those patients (almost half of the population, 45% of the group) who did not increase DMSA must be given. 
Taken together, this study shows that DMSA uptake in patients with cirrhosis and preserved liver function 
increases following IV furosemide (40 or 120 mg), but; 1) this effect is absent in almost half of the patients 
without apparent reasons; 2) this DMSA response does apparently not discriminate those patients who will 
and those who will not develop renal failure (which will be difficult to demonstrate in Child A patients!); 3) the 
DMSA uptake is not correlated to the natriuretic effect of furosemide, and 4) this “dynamic” DMSA uptake is 
not compared to the gold standard for the measurement of GFR (inulin). The consequence of this message 
is a possible overdiagnosis of renal failure in well compensated cirrhotics. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Reject because scientifically unsound What next?: 
 An article of insufficient interest to warrant publication in a scientific/medical journal Level of interest: 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Reviewer's report 
 The Changes in Renal Function after a Single Dose of intravenous Furosemide in Patients with Title: 
Compensated Liver cirrhosis 
 4  20 October 2006 Version: Date: 
 Laurent Spahr Reviewer: 
Reviewer's report: 
General 
The authors have taken into consideration some comments, but I do not see the graphs with individual values of the patients. The manuscript remains difficult to read, with several spelling errors, and results (in the results section) not 
given in a logical order. Abstract : the Background section is not related to the aim and the results of the 
study. 
In particular, the authors must explain why, if they claim that DMSA uptake is a good technique to measure 
GFR, they did observe an increase only in about half of the patients with well compensated, non ascitic 
cirrhosis (in whom renal function is usually preserved). Thus, it may be suggested that the method of DMSA uptake lacks sensitivity and specificity in this setting. Regarding the accuracy of DMSA in the quantification of GFR, it is scientifically incorrect to assess that 
DMSA uptake is superior to measured or calculated creatinine clearance without comparing it with the gold 
standard (that is inulin clearance) in the same patients. 
The characteristics of those patients (almost half of the population, 45% of the group) who did not increase DMSA must be given. 
Taken together, this study shows that DMSA uptake in patients with cirrhosis and preserved liver function 
increases following IV furosemide (40 or 120 mg), but; 1) this effect is absent in almost half of the patients 
without apparent reasons; 2) this DMSA response does apparently not discriminate those patients who will 
and those who will not develop renal failure (which will be difficult to demonstrate in Child A patients!); 3) the 
DMSA uptake is not correlated to the natriuretic effect of furosemide, and 4) this “dynamic” DMSA uptake is 
not compared to the gold standard for the measurement of GFR (inulin). The consequence of this message 
is a possible overdiagnosis of renal failure in well compensated cirrhotics. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Reject because scientifically unsound What next?: 
 An article of insufficient interest to warrant publication in a scientific/medical journal Level of interest: 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Please review this paper.
user
Reviewer's report 
 The Changes in Renal Function after a Single Dose of intravenous Furosemide in Patients with Title: 
Compensated Liver cirrhosis 
 4  20 October 2006 Version: Date: 
 Laurent Spahr Reviewer: 
Reviewer's report: 
General 
The authors have taken into consideration some comments, but I do not see the graphs with individual values of the patients. The manuscript remains difficult to read, with several spelling errors, and results (in the results section) not 
given in a logical order. Abstract : the Background section is not related to the aim and the results of the 
study. 
In particular, the authors must explain why, if they claim that DMSA uptake is a good technique to measure 
GFR, they did observe an increase only in about half of the patients with well compensated, non ascitic 
cirrhosis (in whom renal function is usually preserved). Thus, it may be suggested that the method of DMSA uptake lacks sensitivity and specificity in this setting. Regarding the accuracy of DMSA in the quantification of GFR, it is scientifically incorrect to assess that 
DMSA uptake is superior to measured or calculated creatinine clearance without comparing it with the gold 
standard (that is inulin clearance) in the same patients. 
The characteristics of those patients (almost half of the population, 45% of the group) who did not increase DMSA must be given. 
Taken together, this study shows that DMSA uptake in patients with cirrhosis and preserved liver function 
increases following IV furosemide (40 or 120 mg), but; 1) this effect is absent in almost half of the patients 
without apparent reasons; 2) this DMSA response does apparently not discriminate those patients who will 
and those who will not develop renal failure (which will be difficult to demonstrate in Child A patients!); 3) the 
DMSA uptake is not correlated to the natriuretic effect of furosemide, and 4) this “dynamic” DMSA uptake is 
not compared to the gold standard for the measurement of GFR (inulin). The consequence of this message 
is a possible overdiagnosis of renal failure in well compensated cirrhotics. 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can be reached) 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Reject because scientifically unsound What next?: 
 An article of insufficient interest to warrant publication in a scientific/medical journal Level of interest: 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
assistant