Title: Impacts of Salt Restriction on Nutritional Status, Sarcopenia, and Mortality of Cirrhotic
Patients With Ascites
Version: 3 Date: 06 Feb 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-Although the study is prospective, the lack of random assignment to diet groups raises concerns
about selection bias. The groups are determined based on dietary adherence (as assessed by
questionnaires and urine tests), but without randomization, it is difficult to definitively control
for confounding factors that may influence outcomes (e.g., severity of cirrhosis, comorbid
conditions).
-The exclusion of patients with specific comorbidities (e.g., diabetes, chronic kidney disease) is a
reasonable approach, but there may still be other confounding factors that influence both dietary
adherence and the outcomes measured. These could include socioeconomic status, baseline liver
function, or even subjective factors like patient motivation and lifestyle, which are difficult to
fully control.
-The study mentions a three-month follow-up period, but this may be insufficient to fully capture
long-term changes in nutritional status and muscle mass. Cirrhotic patients with ascites can
have prolonged disease progression, and three months may not be enough to observe significant
changes in mortality or nutritional health, especially in those with advanced cirrhosis.
-The study is focused on observational outcomes such as nutritional status, sarcopenia, and
mortality, but the underlying biological mechanisms through which sodium restriction affects
these outcomes are not explored. Future research could benefit from investigating biochemical
markers (e.g., inflammation, muscle protein synthesis) or hormonal changes (e.g., aldosterone,
cortisol) that could help explain the observed associations.
-The authors effectively highlight that fluid retention complicates body composition
measurements, especially in the SUD group. However, there could be more emphasis on the
challenges of interpreting bioelectrical impedance results in the context of fluid overload. Since
the SUD group had significantly higher total body water (TBW), the authors could clarify further
how this fluid retention may mask the true nutritional status or muscle mass in these patients.
-The authors do well to note the critical role of nutritional support in mitigating the effects of
sodium restriction. However, it would be helpful to explore in more detail the type of nutritional
support that might be most beneficial for cirrhotic patients on a salt-restricted diet. Are there
specific dietary interventions (e.g., higher protein intake, supplementation) that could help
reduce the negative impact of sarcopenia?
Title: Impacts of Salt Restriction on Nutritional Status, Sarcopenia, and Mortality of Cirrhotic
Patients With Ascites
Version: 3 Date: 06 Feb 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-Although the study is prospective, the lack of random assignment to diet groups raises concerns
about selection bias. The groups are determined based on dietary adherence (as assessed by
questionnaires and urine tests), but without randomization, it is difficult to definitively control
for confounding factors that may influence outcomes (e.g., severity of cirrhosis, comorbid
conditions).
-The exclusion of patients with specific comorbidities (e.g., diabetes, chronic kidney disease) is a
reasonable approach, but there may still be other confounding factors that influence both dietary
adherence and the outcomes measured. These could include socioeconomic status, baseline liver
function, or even subjective factors like patient motivation and lifestyle, which are difficult to
fully control.
-The study mentions a three-month follow-up period, but this may be insufficient to fully capture
long-term changes in nutritional status and muscle mass. Cirrhotic patients with ascites can
have prolonged disease progression, and three months may not be enough to observe significant
changes in mortality or nutritional health, especially in those with advanced cirrhosis.
-The study is focused on observational outcomes such as nutritional status, sarcopenia, and
mortality, but the underlying biological mechanisms through which sodium restriction affects
these outcomes are not explored. Future research could benefit from investigating biochemical
markers (e.g., inflammation, muscle protein synthesis) or hormonal changes (e.g., aldosterone,
cortisol) that could help explain the observed associations.
-The authors effectively highlight that fluid retention complicates body composition
measurements, especially in the SUD group. However, there could be more emphasis on the
challenges of interpreting bioelectrical impedance results in the context of fluid overload. Since
the SUD group had significantly higher total body water (TBW), the authors could clarify further
how this fluid retention may mask the true nutritional status or muscle mass in these patients.
-The authors do well to note the critical role of nutritional support in mitigating the effects of
sodium restriction. However, it would be helpful to explore in more detail the type of nutritional
support that might be most beneficial for cirrhotic patients on a salt-restricted diet. Are there
specific dietary interventions (e.g., higher protein intake, supplementation) that could help
reduce the negative impact of sarcopenia?
Please review this paper.
user
Title: Impacts of Salt Restriction on Nutritional Status, Sarcopenia, and Mortality of Cirrhotic
Patients With Ascites
Version: 3 Date: 06 Feb 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-Although the study is prospective, the lack of random assignment to diet groups raises concerns
about selection bias. The groups are determined based on dietary adherence (as assessed by
questionnaires and urine tests), but without randomization, it is difficult to definitively control
for confounding factors that may influence outcomes (e.g., severity of cirrhosis, comorbid
conditions).
-The exclusion of patients with specific comorbidities (e.g., diabetes, chronic kidney disease) is a
reasonable approach, but there may still be other confounding factors that influence both dietary
adherence and the outcomes measured. These could include socioeconomic status, baseline liver
function, or even subjective factors like patient motivation and lifestyle, which are difficult to
fully control.
-The study mentions a three-month follow-up period, but this may be insufficient to fully capture
long-term changes in nutritional status and muscle mass. Cirrhotic patients with ascites can
have prolonged disease progression, and three months may not be enough to observe significant
changes in mortality or nutritional health, especially in those with advanced cirrhosis.
-The study is focused on observational outcomes such as nutritional status, sarcopenia, and
mortality, but the underlying biological mechanisms through which sodium restriction affects
these outcomes are not explored. Future research could benefit from investigating biochemical
markers (e.g., inflammation, muscle protein synthesis) or hormonal changes (e.g., aldosterone,
cortisol) that could help explain the observed associations.
-The authors effectively highlight that fluid retention complicates body composition
measurements, especially in the SUD group. However, there could be more emphasis on the
challenges of interpreting bioelectrical impedance results in the context of fluid overload. Since
the SUD group had significantly higher total body water (TBW), the authors could clarify further
how this fluid retention may mask the true nutritional status or muscle mass in these patients.
-The authors do well to note the critical role of nutritional support in mitigating the effects of
sodium restriction. However, it would be helpful to explore in more detail the type of nutritional
support that might be most beneficial for cirrhotic patients on a salt-restricted diet. Are there
specific dietary interventions (e.g., higher protein intake, supplementation) that could help
reduce the negative impact of sarcopenia?
assistant