Title: Early changes in laboratory tests predict liver function damage in patients with moderate
coronavirus disease 2019: a retrospective multicenter study
Version: 2 Date: 01 Feb 2022
Reviewer's report:
Greetings, definitely a great improvement in reader's experience and learning. I still have,
however, some concerns regarding score use in "real world":
1) In the following statement "In this study, as long as one of the indicators of AST, ALT, GGT,
ALP, TBIL, ALB, TP was outside the reference range, it was defined as liver function damage"
the authors confirm that any value outside the normal reference range was considered as liver
function damage, with a citing study to back up the statement.  In this scenario, a high number of
patients may have been classified as with liver damage without actually having developed such
lesion in histopathology. In critical care setting,  brief changes in routine  exams may be seen
and not relate to actual clinical or permanent alterations. A high number of false positives may
arise in this setting. This may affect the score's  accuracy and wrongly classify patients as high
risk evolution and overwhelm health services critical care. Please, address this potential bias.
Also, to address this matter, I'd suggest further research and validation of the score in other
populations. If feasible, please add this in the paper.
2) I have not mistaken for procalcitonin. The consideration was made based on a similar
statement  as the one on the response "abnormal plateletcrit (PCT) can indicate blood coagulation
dysfunction, and coagulopathy in patients with COVID-19 is related to liver function damage".
To the reader, it seems as all coagulopathy in SARS-CoV-2 infection is associated with liver
damage and we know that is not the case. This should be addressed in the text.
Title: Early changes in laboratory tests predict liver function damage in patients with moderate
coronavirus disease 2019: a retrospective multicenter study
Version: 2 Date: 01 Feb 2022
Reviewer's report:
Greetings, definitely a great improvement in reader's experience and learning. I still have,
however, some concerns regarding score use in "real world":
1) In the following statement "In this study, as long as one of the indicators of AST, ALT, GGT,
ALP, TBIL, ALB, TP was outside the reference range, it was defined as liver function damage"
the authors confirm that any value outside the normal reference range was considered as liver
function damage, with a citing study to back up the statement.  In this scenario, a high number of
patients may have been classified as with liver damage without actually having developed such
lesion in histopathology. In critical care setting,  brief changes in routine  exams may be seen
and not relate to actual clinical or permanent alterations. A high number of false positives may
arise in this setting. This may affect the score's  accuracy and wrongly classify patients as high
risk evolution and overwhelm health services critical care. Please, address this potential bias.
Also, to address this matter, I'd suggest further research and validation of the score in other
populations. If feasible, please add this in the paper.
2) I have not mistaken for procalcitonin. The consideration was made based on a similar
statement  as the one on the response "abnormal plateletcrit (PCT) can indicate blood coagulation
dysfunction, and coagulopathy in patients with COVID-19 is related to liver function damage".
To the reader, it seems as all coagulopathy in SARS-CoV-2 infection is associated with liver
damage and we know that is not the case. This should be addressed in the text.
Please review this paper.
user
Title: Early changes in laboratory tests predict liver function damage in patients with moderate
coronavirus disease 2019: a retrospective multicenter study
Version: 2 Date: 01 Feb 2022
Reviewer's report:
Greetings, definitely a great improvement in reader's experience and learning. I still have,
however, some concerns regarding score use in "real world":
1) In the following statement "In this study, as long as one of the indicators of AST, ALT, GGT,
ALP, TBIL, ALB, TP was outside the reference range, it was defined as liver function damage"
the authors confirm that any value outside the normal reference range was considered as liver
function damage, with a citing study to back up the statement.  In this scenario, a high number of
patients may have been classified as with liver damage without actually having developed such
lesion in histopathology. In critical care setting,  brief changes in routine  exams may be seen
and not relate to actual clinical or permanent alterations. A high number of false positives may
arise in this setting. This may affect the score's  accuracy and wrongly classify patients as high
risk evolution and overwhelm health services critical care. Please, address this potential bias.
Also, to address this matter, I'd suggest further research and validation of the score in other
populations. If feasible, please add this in the paper.
2) I have not mistaken for procalcitonin. The consideration was made based on a similar
statement  as the one on the response "abnormal plateletcrit (PCT) can indicate blood coagulation
dysfunction, and coagulopathy in patients with COVID-19 is related to liver function damage".
To the reader, it seems as all coagulopathy in SARS-CoV-2 infection is associated with liver
damage and we know that is not the case. This should be addressed in the text.
assistant