Reviewer's report
Title:The usefulness of C-reactive protein and neutrophil-to-lymphocyte ratio for
predicting the outcome in hospitalized patients with liver cirrhosis
Version:1Date:31 July 2015
Reviewer: David G Watt
Reviewer's report:
The authors report the use of CRP and NLR to diagnose infections and predict
outcomes in cirrhotic patients admitted to hospital. They include 184 patients and
conclude that CRP was a significant indicator of infection and elevated NLR a
poor predictor of 1 month survival.
Major Revision:
The question is defined well althought it is well known that CRP is useful in
helping predict those who will develop infection, methods appropriate, data
sound, figures genuine there are a few major revisions that need to be
addressed:
1. in the results section of abstract and manuscript the authors state the odds
ratio for CRP and the presence of SIRS to be 1.017 yet a highly significant p
value. I cant quite understand this, can they check the statistical methods?
2. The conclusions of the abstract state NLR is a poor predictor of 1 month
survival in one sentence then in the next one state CRP and NLR are good
predictors of outcomes? These 2 statements contradict each other.
3. They mention in the methods that cirrhosis was diagnosed on biopsy or on
"obvious clinical, biochemical and imaging features". They should specifically
mention what these were.
4. The study states that all the hospitalized patients were treated with empiric
broad spectrum antibiotics at admission. Surely this is a confounder to the study?
Could patients with mild SIRS have been treated and therefore their results did
not trigger a rise in CRP? I dont understand how the study can be aiming to look
at whether CRP and NLR can improve diagnostic accuracy of infection when
everyone gets antibiotics anyway, does it matter what the CRP levels were then?
They are being treated at any rate, I really struggled with this concept
5. In discussion the authors mention cirrhosis causes low WBC counts but
alcoholic cirrhosis patients can have high WBC even without infection. Therefore
how can NLR have a role? The neutrophil count can be high or low without
infection on board and therefore in my opinion in cannot be used to diagnose
infection as other parameters will alter its result. This would appear to be a major
flaw in this study
6. Did the authors look at the role of neutrophils on their own? Recent reports
have suggested that the majority of the prognostic component of the NLR come
from the neutrophil count itself.
7. Again I am confused as to the statements in the conclusion. The authors state
patients with elevated CRP and NLR should be monitored carefully for presence
of infection and considered for prompt antibiotic therapy - but are they not
already on antibiotics and therefore being treated regardless?
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests
Reviewer's report
Title:The usefulness of C-reactive protein and neutrophil-to-lymphocyte ratio for
predicting the outcome in hospitalized patients with liver cirrhosis
Version:1Date:31 July 2015
Reviewer: David G Watt
Reviewer's report:
The authors report the use of CRP and NLR to diagnose infections and predict
outcomes in cirrhotic patients admitted to hospital. They include 184 patients and
conclude that CRP was a significant indicator of infection and elevated NLR a
poor predictor of 1 month survival.
Major Revision:
The question is defined well althought it is well known that CRP is useful in
helping predict those who will develop infection, methods appropriate, data
sound, figures genuine there are a few major revisions that need to be
addressed:
1. in the results section of abstract and manuscript the authors state the odds
ratio for CRP and the presence of SIRS to be 1.017 yet a highly significant p
value. I cant quite understand this, can they check the statistical methods?
2. The conclusions of the abstract state NLR is a poor predictor of 1 month
survival in one sentence then in the next one state CRP and NLR are good
predictors of outcomes? These 2 statements contradict each other.
3. They mention in the methods that cirrhosis was diagnosed on biopsy or on
"obvious clinical, biochemical and imaging features". They should specifically
mention what these were.
4. The study states that all the hospitalized patients were treated with empiric
broad spectrum antibiotics at admission. Surely this is a confounder to the study?
Could patients with mild SIRS have been treated and therefore their results did
not trigger a rise in CRP? I dont understand how the study can be aiming to look
at whether CRP and NLR can improve diagnostic accuracy of infection when
everyone gets antibiotics anyway, does it matter what the CRP levels were then?
They are being treated at any rate, I really struggled with this concept
5. In discussion the authors mention cirrhosis causes low WBC counts but
alcoholic cirrhosis patients can have high WBC even without infection. Therefore
how can NLR have a role? The neutrophil count can be high or low without
infection on board and therefore in my opinion in cannot be used to diagnose
infection as other parameters will alter its result. This would appear to be a major
flaw in this study
6. Did the authors look at the role of neutrophils on their own? Recent reports
have suggested that the majority of the prognostic component of the NLR come
from the neutrophil count itself.
7. Again I am confused as to the statements in the conclusion. The authors state
patients with elevated CRP and NLR should be monitored carefully for presence
of infection and considered for prompt antibiotic therapy - but are they not
already on antibiotics and therefore being treated regardless?
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests
Please review this paper.
user
Reviewer's report
Title:The usefulness of C-reactive protein and neutrophil-to-lymphocyte ratio for
predicting the outcome in hospitalized patients with liver cirrhosis
Version:1Date:31 July 2015
Reviewer: David G Watt
Reviewer's report:
The authors report the use of CRP and NLR to diagnose infections and predict
outcomes in cirrhotic patients admitted to hospital. They include 184 patients and
conclude that CRP was a significant indicator of infection and elevated NLR a
poor predictor of 1 month survival.
Major Revision:
The question is defined well althought it is well known that CRP is useful in
helping predict those who will develop infection, methods appropriate, data
sound, figures genuine there are a few major revisions that need to be
addressed:
1. in the results section of abstract and manuscript the authors state the odds
ratio for CRP and the presence of SIRS to be 1.017 yet a highly significant p
value. I cant quite understand this, can they check the statistical methods?
2. The conclusions of the abstract state NLR is a poor predictor of 1 month
survival in one sentence then in the next one state CRP and NLR are good
predictors of outcomes? These 2 statements contradict each other.
3. They mention in the methods that cirrhosis was diagnosed on biopsy or on
"obvious clinical, biochemical and imaging features". They should specifically
mention what these were.
4. The study states that all the hospitalized patients were treated with empiric
broad spectrum antibiotics at admission. Surely this is a confounder to the study?
Could patients with mild SIRS have been treated and therefore their results did
not trigger a rise in CRP? I dont understand how the study can be aiming to look
at whether CRP and NLR can improve diagnostic accuracy of infection when
everyone gets antibiotics anyway, does it matter what the CRP levels were then?
They are being treated at any rate, I really struggled with this concept
5. In discussion the authors mention cirrhosis causes low WBC counts but
alcoholic cirrhosis patients can have high WBC even without infection. Therefore
how can NLR have a role? The neutrophil count can be high or low without
infection on board and therefore in my opinion in cannot be used to diagnose
infection as other parameters will alter its result. This would appear to be a major
flaw in this study
6. Did the authors look at the role of neutrophils on their own? Recent reports
have suggested that the majority of the prognostic component of the NLR come
from the neutrophil count itself.
7. Again I am confused as to the statements in the conclusion. The authors state
patients with elevated CRP and NLR should be monitored carefully for presence
of infection and considered for prompt antibiotic therapy - but are they not
already on antibiotics and therefore being treated regardless?
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests
assistant