Title: Reduced muscle mass is an important part of Global Leadership Initiative on Malnutrition
criteria in nutritional diagnosis of hepatocellular carcinoma
Version: 4 Date: 29 Aug 2024
Reviewer's report:
Li et al. presented a study looking at the association between reduced muscle mass in Global
Leadership Initiative on Malnutrition in the mortality risk of patients with HCC. They found
that the GLIM was independently associated with increased risk of mortality. Further, including
CT assessed muscle mass as an extra indicator increased the sensitivity of GLIM in identifying
patients with malnutrition, and it also showed independent association with HCC mortality in
hospital.
The results presented with thorough details in a scientific manner. However my major concerns
are
1. HCC is one of the major outcomes of chronic liver diseases. Major factors associated with
the mortality risk of patients with HCC are factors mainly associated with chronic liver disease
such as portal hypertension and liver decompensation, but not so much are factors with HCC per
se (tumour invasion, etc). This is drastically different from other types of major organ cancers.
However, the authors didn’t discuss factors associated with liver decompensation, nor tumour
invasion including HCC staging at baseline, tumour number and sizes, any tumour metastases, or
any HCC treatment. Although undoubtedly nutritional status is associated with health outcomes
in patients with HCC, a conclusion drawn by excluding adjustments of these major factors would
not be anyway near accurate.
2. For patients with chronic liver disease, HCC and other liver decompensation outcomes will
most likely occur around the same time. In this study cohort, did all the patients have only HCC
but not other liver decompensation? As authors listed in Table 1, short-term outcomes included
HE, ascites, etc. However, my argument is that these outcomes especially ascites, had occurred
before or around the same time as HCC, therefore it couldn’t be labelled as an outcome. As
discussed above, none of these are outcomes of HCC. They are outcomes of chronic liver disease.
This would be a logical, not necessarily a clinical issue, in analysing and interpreting the survival
data. Patients with malnutrition had worse liver outcomes than patients without malnutrition,
which has been published widely, and has little to do with the HCC status.
3. What is the exact purpose of excluding muscle mass as a diagnosis criterion in GLIM in the
first part of data analysis? The GLIM criteria have clearly listed reduced muscle mass as one of
the phenotypic criteria published in 2019. If accessibility is the reason, authors need to discuss
this further.
4. Figure 3 is a bit confusing, did the authors try to predict the total mortality risk by nutritional
status alone? What is the clinical significance of this analysis?
Title: Reduced muscle mass is an important part of Global Leadership Initiative on Malnutrition
criteria in nutritional diagnosis of hepatocellular carcinoma
Version: 4 Date: 29 Aug 2024
Reviewer's report:
Li et al. presented a study looking at the association between reduced muscle mass in Global
Leadership Initiative on Malnutrition in the mortality risk of patients with HCC. They found
that the GLIM was independently associated with increased risk of mortality. Further, including
CT assessed muscle mass as an extra indicator increased the sensitivity of GLIM in identifying
patients with malnutrition, and it also showed independent association with HCC mortality in
hospital.
The results presented with thorough details in a scientific manner. However my major concerns
are
1. HCC is one of the major outcomes of chronic liver diseases. Major factors associated with
the mortality risk of patients with HCC are factors mainly associated with chronic liver disease
such as portal hypertension and liver decompensation, but not so much are factors with HCC per
se (tumour invasion, etc). This is drastically different from other types of major organ cancers.
However, the authors didn’t discuss factors associated with liver decompensation, nor tumour
invasion including HCC staging at baseline, tumour number and sizes, any tumour metastases, or
any HCC treatment. Although undoubtedly nutritional status is associated with health outcomes
in patients with HCC, a conclusion drawn by excluding adjustments of these major factors would
not be anyway near accurate.
2. For patients with chronic liver disease, HCC and other liver decompensation outcomes will
most likely occur around the same time. In this study cohort, did all the patients have only HCC
but not other liver decompensation? As authors listed in Table 1, short-term outcomes included
HE, ascites, etc. However, my argument is that these outcomes especially ascites, had occurred
before or around the same time as HCC, therefore it couldn’t be labelled as an outcome. As
discussed above, none of these are outcomes of HCC. They are outcomes of chronic liver disease.
This would be a logical, not necessarily a clinical issue, in analysing and interpreting the survival
data. Patients with malnutrition had worse liver outcomes than patients without malnutrition,
which has been published widely, and has little to do with the HCC status.
3. What is the exact purpose of excluding muscle mass as a diagnosis criterion in GLIM in the
first part of data analysis? The GLIM criteria have clearly listed reduced muscle mass as one of
the phenotypic criteria published in 2019. If accessibility is the reason, authors need to discuss
this further.
4. Figure 3 is a bit confusing, did the authors try to predict the total mortality risk by nutritional
status alone? What is the clinical significance of this analysis?
Please review this paper.
user
Title: Reduced muscle mass is an important part of Global Leadership Initiative on Malnutrition
criteria in nutritional diagnosis of hepatocellular carcinoma
Version: 4 Date: 29 Aug 2024
Reviewer's report:
Li et al. presented a study looking at the association between reduced muscle mass in Global
Leadership Initiative on Malnutrition in the mortality risk of patients with HCC. They found
that the GLIM was independently associated with increased risk of mortality. Further, including
CT assessed muscle mass as an extra indicator increased the sensitivity of GLIM in identifying
patients with malnutrition, and it also showed independent association with HCC mortality in
hospital.
The results presented with thorough details in a scientific manner. However my major concerns
are
1. HCC is one of the major outcomes of chronic liver diseases. Major factors associated with
the mortality risk of patients with HCC are factors mainly associated with chronic liver disease
such as portal hypertension and liver decompensation, but not so much are factors with HCC per
se (tumour invasion, etc). This is drastically different from other types of major organ cancers.
However, the authors didn’t discuss factors associated with liver decompensation, nor tumour
invasion including HCC staging at baseline, tumour number and sizes, any tumour metastases, or
any HCC treatment. Although undoubtedly nutritional status is associated with health outcomes
in patients with HCC, a conclusion drawn by excluding adjustments of these major factors would
not be anyway near accurate.
2. For patients with chronic liver disease, HCC and other liver decompensation outcomes will
most likely occur around the same time. In this study cohort, did all the patients have only HCC
but not other liver decompensation? As authors listed in Table 1, short-term outcomes included
HE, ascites, etc. However, my argument is that these outcomes especially ascites, had occurred
before or around the same time as HCC, therefore it couldn’t be labelled as an outcome. As
discussed above, none of these are outcomes of HCC. They are outcomes of chronic liver disease.
This would be a logical, not necessarily a clinical issue, in analysing and interpreting the survival
data. Patients with malnutrition had worse liver outcomes than patients without malnutrition,
which has been published widely, and has little to do with the HCC status.
3. What is the exact purpose of excluding muscle mass as a diagnosis criterion in GLIM in the
first part of data analysis? The GLIM criteria have clearly listed reduced muscle mass as one of
the phenotypic criteria published in 2019. If accessibility is the reason, authors need to discuss
this further.
4. Figure 3 is a bit confusing, did the authors try to predict the total mortality risk by nutritional
status alone? What is the clinical significance of this analysis?
assistant