Title: Characteristics of acute kidney injury and its impact on outcome in patients with acute-
on-chronic liver failure
Version: 0 Date: 13 Feb 2022
Reviewer's report:
Huang Y et al present a retrospective cohort study entitled "Characteristics of acute kidney injury
and its impact on outcome in patients with acute-on-chronic liver failure". With this study they
aimed to assess risk factors for AKI development among patients with cirrhosis admitted to the
hospital.
They have used a fairly large training set (n=574) from a single centre to describe AKI in
patients with ACLF (defined by APAPL), mainly with HBV as underlying cause. They have
differentiated CA AKI from HA AKI. They then developed a predictive model to predict the risk
of HA AKI with 7 variables to compute (age, GI bleed, infection, BUN, PT, Bilirubin, Albumin).
Finally, they validated this model in a different smaller cohort.
The novelty of these findings is not impressive. However, the fact that this constitutes a cohort
of patients with cirrhosis from China, where HBV infection represents almost half of all cases,
may be of interest for the readership mostly from there.
Major comments:
1.The introduction could detail better possible mechanisms of AKI in patients with cirrhosis,
including those from sepsis.
2.How did you define cirrhosis?
3.How did excluded patients with predicted life expectancy of less than 3 days? Do you mean
by this you excluded patients lacking that follow-up period?
4.The missing values should be presented at least as %.
5.Why use Hosmer-Lemeshow to test the models' fit with all its limitations?
6.How many patients required ICU admission and RRT (any protocol for starting)?
7.How many patients went on to receive a liver transplant?
8.Why did you exclude CA AKI? Why did you select only potential individual predictors that
were statistically significant as this may excluded other clinically relevant? You should detail
better the rationale to do this. Furthermore, was there collinearity among predictors?
9.Please describe better how you found your discrimination and calibration between training
and validation sets to worth.
10.As you detail in the Discussion section, to compare your index with previous ones not
developed for this purpose is not much informative.
11.How did you define pre-renal azotaemia, ATN and HRS?
12.The discussion is extremely lengthy and has a lot of information from previous studies that
do not add anything new. I would concentrate on debating about the main findings.
13.Comments such as "In this study, almost 40% of the patients had AKI, which could be avoided
by eliminating its risk factors." are very difficult to accept. If this was possible to do, it would
be nice, but it is unlikely.
14.This other comment "This means that patients with alcohol liver disease may have a better
prognosis of AKI than those with other types of chronic liver disease" is also difficult to interpret.
15.The Abstract should target the main findings about the risk index for HA AKI.
Minor comments
1.The article would benefit of being much shorter.
Title: Characteristics of acute kidney injury and its impact on outcome in patients with acute-
on-chronic liver failure
Version: 0 Date: 13 Feb 2022
Reviewer's report:
Huang Y et al present a retrospective cohort study entitled "Characteristics of acute kidney injury
and its impact on outcome in patients with acute-on-chronic liver failure". With this study they
aimed to assess risk factors for AKI development among patients with cirrhosis admitted to the
hospital.
They have used a fairly large training set (n=574) from a single centre to describe AKI in
patients with ACLF (defined by APAPL), mainly with HBV as underlying cause. They have
differentiated CA AKI from HA AKI. They then developed a predictive model to predict the risk
of HA AKI with 7 variables to compute (age, GI bleed, infection, BUN, PT, Bilirubin, Albumin).
Finally, they validated this model in a different smaller cohort.
The novelty of these findings is not impressive. However, the fact that this constitutes a cohort
of patients with cirrhosis from China, where HBV infection represents almost half of all cases,
may be of interest for the readership mostly from there.
Major comments:
1.The introduction could detail better possible mechanisms of AKI in patients with cirrhosis,
including those from sepsis.
2.How did you define cirrhosis?
3.How did excluded patients with predicted life expectancy of less than 3 days? Do you mean
by this you excluded patients lacking that follow-up period?
4.The missing values should be presented at least as %.
5.Why use Hosmer-Lemeshow to test the models' fit with all its limitations?
6.How many patients required ICU admission and RRT (any protocol for starting)?
7.How many patients went on to receive a liver transplant?
8.Why did you exclude CA AKI? Why did you select only potential individual predictors that
were statistically significant as this may excluded other clinically relevant? You should detail
better the rationale to do this. Furthermore, was there collinearity among predictors?
9.Please describe better how you found your discrimination and calibration between training
and validation sets to worth.
10.As you detail in the Discussion section, to compare your index with previous ones not
developed for this purpose is not much informative.
11.How did you define pre-renal azotaemia, ATN and HRS?
12.The discussion is extremely lengthy and has a lot of information from previous studies that
do not add anything new. I would concentrate on debating about the main findings.
13.Comments such as "In this study, almost 40% of the patients had AKI, which could be avoided
by eliminating its risk factors." are very difficult to accept. If this was possible to do, it would
be nice, but it is unlikely.
14.This other comment "This means that patients with alcohol liver disease may have a better
prognosis of AKI than those with other types of chronic liver disease" is also difficult to interpret.
15.The Abstract should target the main findings about the risk index for HA AKI.
Minor comments
1.The article would benefit of being much shorter.
Please review this paper.
user
Title: Characteristics of acute kidney injury and its impact on outcome in patients with acute-
on-chronic liver failure
Version: 0 Date: 13 Feb 2022
Reviewer's report:
Huang Y et al present a retrospective cohort study entitled "Characteristics of acute kidney injury
and its impact on outcome in patients with acute-on-chronic liver failure". With this study they
aimed to assess risk factors for AKI development among patients with cirrhosis admitted to the
hospital.
They have used a fairly large training set (n=574) from a single centre to describe AKI in
patients with ACLF (defined by APAPL), mainly with HBV as underlying cause. They have
differentiated CA AKI from HA AKI. They then developed a predictive model to predict the risk
of HA AKI with 7 variables to compute (age, GI bleed, infection, BUN, PT, Bilirubin, Albumin).
Finally, they validated this model in a different smaller cohort.
The novelty of these findings is not impressive. However, the fact that this constitutes a cohort
of patients with cirrhosis from China, where HBV infection represents almost half of all cases,
may be of interest for the readership mostly from there.
Major comments:
1.The introduction could detail better possible mechanisms of AKI in patients with cirrhosis,
including those from sepsis.
2.How did you define cirrhosis?
3.How did excluded patients with predicted life expectancy of less than 3 days? Do you mean
by this you excluded patients lacking that follow-up period?
4.The missing values should be presented at least as %.
5.Why use Hosmer-Lemeshow to test the models' fit with all its limitations?
6.How many patients required ICU admission and RRT (any protocol for starting)?
7.How many patients went on to receive a liver transplant?
8.Why did you exclude CA AKI? Why did you select only potential individual predictors that
were statistically significant as this may excluded other clinically relevant? You should detail
better the rationale to do this. Furthermore, was there collinearity among predictors?
9.Please describe better how you found your discrimination and calibration between training
and validation sets to worth.
10.As you detail in the Discussion section, to compare your index with previous ones not
developed for this purpose is not much informative.
11.How did you define pre-renal azotaemia, ATN and HRS?
12.The discussion is extremely lengthy and has a lot of information from previous studies that
do not add anything new. I would concentrate on debating about the main findings.
13.Comments such as "In this study, almost 40% of the patients had AKI, which could be avoided
by eliminating its risk factors." are very difficult to accept. If this was possible to do, it would
be nice, but it is unlikely.
14.This other comment "This means that patients with alcohol liver disease may have a better
prognosis of AKI than those with other types of chronic liver disease" is also difficult to interpret.
15.The Abstract should target the main findings about the risk index for HA AKI.
Minor comments
1.The article would benefit of being much shorter.
assistant