Reviewer's report 
 Serum hyaluronate as a non invasive marker of hepatic fibrosis and inflammation in chronic Title: 
HBV infection 
 1  26 April 2005 Version: Date: 
 Edoardo Giovanni Giannini Reviewer: 
Reviewer's report: 
General 
The study by Montazeri and Co-workers deals with an important issue in clinical hepatology. Chronic 
HBV infection is a major world-wide health concern. Non-invasive assessment of disease stage and 
liver inflammation can be of help for the management of patients with chronic hepatitis B. In this 
study the Authors assessed the accuracy of hyaluronic acid (HA) for the diagnosis of advanced 
fibrosis (and inflammation) in a group of patients chronically infected by HBV. They found that, on the average, HA levels are higher in patients with decompensated cirrhosis as compared to both 
chronic hepatitis patients and controls. Furthermore, among chronic hepatitis patients, those with 
advanced fibrosis have higher HA as compared to patients with mild fibrosis. However, HA serum levels of chronic hepatitis patients as a whole are not significantly different from those of health 
controls. Finally, the Authors evaluated, by means of ROC curves, the accuracy of different HA 
cut-offs for diagnosing advanced fibrosis or decompensated cirrhosis. 
The results of the study are quite interesting, and I actually appreciated the cautious conclusions 
expressed by the Authors. There are some limitations to the study, mainly patients distribution and 
the limited usefulness of HA to discriminate between two conditions that can be easily discriminated 
on a clinical basis alone (chronic hepatitis versus decompensated cirrhosis). 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
1.The Authors evaluated a relatively small cohort of subjects. Eleven patients alone had advanced 
fibrosis and 68 mild fibrosis. They found a marked difference in mean HA levels between the two 
subgroups of patients (28 versus 309 ng/mL), and actually HA levels of patients with mild fibrosis 
are not different from those of healthy controls (20 ng/mL). This is likely due to imbalance in patients 
distribution. This is not a negligible point, since HA seems to be useful for identifying patients with 
advanced fibrosis (and therefore more in the need of anti-viral therapy), but falls short to identify 
patients with initial fibrosis. The Authors need to discuss this result. 
2.The analysis of HA levels in patients with decompensated disease is important in order to show the progressive increase in HA as liver disease worsens. However, I am not sure that the detailed analysis of ROC curve and the identification of a HA cut-off able to discriminate between 
decompensated cirrhosis and chronic hepatitis adds something to the study. Indeed, these two 
clinical entities can be easily identified on clinical grounds, and therefore in this setting the use of HA 
seems to be redundant. 
3.A group of patients with compensated cirrhosis is lacking. In fact, the Authors evaluated patients 
with fibrosis score up to 5 (i.e., probable cirrhosis, according to the Ishaks score) but no patients with 
fibrosis score 6. This is a major drawback of the study, since identification of the presence of 
compensated cirrhosis in patients with chronic liver disease is of fundamental importance for therapeutic and prognostic implications. The Authors need to detail the reasons for such exclusion. 
A further group of patients with compensated disease (and analysis of a HA cut-off able to separate 
this sub-group from the others) would greatly improve the message of the study. 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
1.Criteria for selection of patients are not clear. It seems that the Authors retrospectively selected 
their patients rather assessing consecutive patients. Detailed description of criteria for inclusion and exclusion together with the number of patients excluded needs to be shown in the Result section of the manuscript. 
2.In the Discussion section of the manuscript the second statement is not supported by the study 
results. In fact, HA serum levels are not significantly higher in CHB patients as compared to controls 
(p=0.33). 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
1.Some abbreviations (such as CHB) need to be cited in the text (mot in the abstract). 
2.Reference #7 is not appropriate. 
3.References #16 and #17 are not pertinent to the context in which they are cited. 4.Page 4, 5th line: propeptideds should be propeptides. 5.Page5, 2nd paragraph, 2nd line: Pough should be Pugh and Percutneous should be 
percutaneous. 
6.Page 6, Corgnix should be Corgenix. 
7.Results: please express age of the patients as integer. 
8.Page 8, 4th line from the end: phosphatease should be phosphatase. 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
'I declare that I have no competing interests' 
Reviewer's report 
 Serum hyaluronate as a non invasive marker of hepatic fibrosis and inflammation in chronic Title: 
HBV infection 
 1  26 April 2005 Version: Date: 
 Edoardo Giovanni Giannini Reviewer: 
Reviewer's report: 
General 
The study by Montazeri and Co-workers deals with an important issue in clinical hepatology. Chronic 
HBV infection is a major world-wide health concern. Non-invasive assessment of disease stage and 
liver inflammation can be of help for the management of patients with chronic hepatitis B. In this 
study the Authors assessed the accuracy of hyaluronic acid (HA) for the diagnosis of advanced 
fibrosis (and inflammation) in a group of patients chronically infected by HBV. They found that, on the average, HA levels are higher in patients with decompensated cirrhosis as compared to both 
chronic hepatitis patients and controls. Furthermore, among chronic hepatitis patients, those with 
advanced fibrosis have higher HA as compared to patients with mild fibrosis. However, HA serum levels of chronic hepatitis patients as a whole are not significantly different from those of health 
controls. Finally, the Authors evaluated, by means of ROC curves, the accuracy of different HA 
cut-offs for diagnosing advanced fibrosis or decompensated cirrhosis. 
The results of the study are quite interesting, and I actually appreciated the cautious conclusions 
expressed by the Authors. There are some limitations to the study, mainly patients distribution and 
the limited usefulness of HA to discriminate between two conditions that can be easily discriminated 
on a clinical basis alone (chronic hepatitis versus decompensated cirrhosis). 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
1.The Authors evaluated a relatively small cohort of subjects. Eleven patients alone had advanced 
fibrosis and 68 mild fibrosis. They found a marked difference in mean HA levels between the two 
subgroups of patients (28 versus 309 ng/mL), and actually HA levels of patients with mild fibrosis 
are not different from those of healthy controls (20 ng/mL). This is likely due to imbalance in patients 
distribution. This is not a negligible point, since HA seems to be useful for identifying patients with 
advanced fibrosis (and therefore more in the need of anti-viral therapy), but falls short to identify 
patients with initial fibrosis. The Authors need to discuss this result. 
2.The analysis of HA levels in patients with decompensated disease is important in order to show the progressive increase in HA as liver disease worsens. However, I am not sure that the detailed analysis of ROC curve and the identification of a HA cut-off able to discriminate between 
decompensated cirrhosis and chronic hepatitis adds something to the study. Indeed, these two 
clinical entities can be easily identified on clinical grounds, and therefore in this setting the use of HA 
seems to be redundant. 
3.A group of patients with compensated cirrhosis is lacking. In fact, the Authors evaluated patients 
with fibrosis score up to 5 (i.e., probable cirrhosis, according to the Ishaks score) but no patients with 
fibrosis score 6. This is a major drawback of the study, since identification of the presence of 
compensated cirrhosis in patients with chronic liver disease is of fundamental importance for therapeutic and prognostic implications. The Authors need to detail the reasons for such exclusion. 
A further group of patients with compensated disease (and analysis of a HA cut-off able to separate 
this sub-group from the others) would greatly improve the message of the study. 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
1.Criteria for selection of patients are not clear. It seems that the Authors retrospectively selected 
their patients rather assessing consecutive patients. Detailed description of criteria for inclusion and exclusion together with the number of patients excluded needs to be shown in the Result section of the manuscript. 
2.In the Discussion section of the manuscript the second statement is not supported by the study 
results. In fact, HA serum levels are not significantly higher in CHB patients as compared to controls 
(p=0.33). 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
1.Some abbreviations (such as CHB) need to be cited in the text (mot in the abstract). 
2.Reference #7 is not appropriate. 
3.References #16 and #17 are not pertinent to the context in which they are cited. 4.Page 4, 5th line: propeptideds should be propeptides. 5.Page5, 2nd paragraph, 2nd line: Pough should be Pugh and Percutneous should be 
percutaneous. 
6.Page 6, Corgnix should be Corgenix. 
7.Results: please express age of the patients as integer. 
8.Page 8, 4th line from the end: phosphatease should be phosphatase. 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
'I declare that I have no competing interests' 
Please review this paper.
user
Reviewer's report 
 Serum hyaluronate as a non invasive marker of hepatic fibrosis and inflammation in chronic Title: 
HBV infection 
 1  26 April 2005 Version: Date: 
 Edoardo Giovanni Giannini Reviewer: 
Reviewer's report: 
General 
The study by Montazeri and Co-workers deals with an important issue in clinical hepatology. Chronic 
HBV infection is a major world-wide health concern. Non-invasive assessment of disease stage and 
liver inflammation can be of help for the management of patients with chronic hepatitis B. In this 
study the Authors assessed the accuracy of hyaluronic acid (HA) for the diagnosis of advanced 
fibrosis (and inflammation) in a group of patients chronically infected by HBV. They found that, on the average, HA levels are higher in patients with decompensated cirrhosis as compared to both 
chronic hepatitis patients and controls. Furthermore, among chronic hepatitis patients, those with 
advanced fibrosis have higher HA as compared to patients with mild fibrosis. However, HA serum levels of chronic hepatitis patients as a whole are not significantly different from those of health 
controls. Finally, the Authors evaluated, by means of ROC curves, the accuracy of different HA 
cut-offs for diagnosing advanced fibrosis or decompensated cirrhosis. 
The results of the study are quite interesting, and I actually appreciated the cautious conclusions 
expressed by the Authors. There are some limitations to the study, mainly patients distribution and 
the limited usefulness of HA to discriminate between two conditions that can be easily discriminated 
on a clinical basis alone (chronic hepatitis versus decompensated cirrhosis). 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
1.The Authors evaluated a relatively small cohort of subjects. Eleven patients alone had advanced 
fibrosis and 68 mild fibrosis. They found a marked difference in mean HA levels between the two 
subgroups of patients (28 versus 309 ng/mL), and actually HA levels of patients with mild fibrosis 
are not different from those of healthy controls (20 ng/mL). This is likely due to imbalance in patients 
distribution. This is not a negligible point, since HA seems to be useful for identifying patients with 
advanced fibrosis (and therefore more in the need of anti-viral therapy), but falls short to identify 
patients with initial fibrosis. The Authors need to discuss this result. 
2.The analysis of HA levels in patients with decompensated disease is important in order to show the progressive increase in HA as liver disease worsens. However, I am not sure that the detailed analysis of ROC curve and the identification of a HA cut-off able to discriminate between 
decompensated cirrhosis and chronic hepatitis adds something to the study. Indeed, these two 
clinical entities can be easily identified on clinical grounds, and therefore in this setting the use of HA 
seems to be redundant. 
3.A group of patients with compensated cirrhosis is lacking. In fact, the Authors evaluated patients 
with fibrosis score up to 5 (i.e., probable cirrhosis, according to the Ishaks score) but no patients with 
fibrosis score 6. This is a major drawback of the study, since identification of the presence of 
compensated cirrhosis in patients with chronic liver disease is of fundamental importance for therapeutic and prognostic implications. The Authors need to detail the reasons for such exclusion. 
A further group of patients with compensated disease (and analysis of a HA cut-off able to separate 
this sub-group from the others) would greatly improve the message of the study. 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the author can be trusted to correct) 
1.Criteria for selection of patients are not clear. It seems that the Authors retrospectively selected 
their patients rather assessing consecutive patients. Detailed description of criteria for inclusion and exclusion together with the number of patients excluded needs to be shown in the Result section of the manuscript. 
2.In the Discussion section of the manuscript the second statement is not supported by the study 
results. In fact, HA serum levels are not significantly higher in CHB patients as compared to controls 
(p=0.33). 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
1.Some abbreviations (such as CHB) need to be cited in the text (mot in the abstract). 
2.Reference #7 is not appropriate. 
3.References #16 and #17 are not pertinent to the context in which they are cited. 4.Page 4, 5th line: propeptideds should be propeptides. 5.Page5, 2nd paragraph, 2nd line: Pough should be Pugh and Percutneous should be 
percutaneous. 
6.Page 6, Corgnix should be Corgenix. 
7.Results: please express age of the patients as integer. 
8.Page 8, 4th line from the end: phosphatease should be phosphatase. 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article whose findings are important to those with closely related research Level of interest: 
interests 
 Needs some language corrections before being published Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
'I declare that I have no competing interests' 
assistant