Title: Association of Thromboelastography Profile with Severity of Liver Cirrhosis and Portal
Venous System Thrombosis
Version: 1 Date: 21 Mar 2021
Reviewer:  Iliana Mani
Reviewer's report:
Dear Authors,
Cirrhosis has long been considered an acquired hemorrhagic disorder. However, in recent
years became clear that hemostasis in cirrhosis is rather “rebalanced”, as decreases in
procoagulant factors are accompanied by reduced levels of natural anticoagulants. Viscoelastic
tests significantly contributed to the better understanding of this complicated relationship,
providing information about the “in vivo” hemostatic procedure.
Thrombosis of the portal venous system occurs in a significant proportion of cirrhotic patients,
been more frequent in the advanced stages of liver disease. Although it is a well-known
complication, issues in regard to prognostic factors for its development, appropriate treatment
and duration of treatment are still under debate.
The current study is of great interest as it could improve our understanding about the
characteristics of hemostasis of patients presenting with portal venous system thrombosis and
subsequently to contribute to the better treatment or even prophylaxis of the vulnerable patients.
Major comments:
1) Authors should explain briefly the phases of hemostasis expressed by the variables of TEG
under study as well as the conventional coagulation factor(s) that are involved in each phase.
2) Fibrinogen is a key element for hemostasis. In TEG, its impairment leads to alternations both
of K and a-angle. Authors should mention levels of fibrinogen and study its correlation with
TEG parameters.
3) Authors should provide more information about the selection of criteria used to characterize
hypercoagulability as there is great discrepancy among the different studies and I did not find
a universal definition in regard to TEG.
4) A comparison between proportion of patients with values under or above the reference limit
would be significantly more informative than the comparison of median values between the
subgroups of interest.
5) Page 11, lines 221-223. R variable reflects the initiation of clot formation and is highly
dependent on coagulation factors. Both qualitative and quantitative platelets’ abnormalities are
accompanied by normal or near normal R. On the contrary, K and a angle are dependent mainly
on fibrinogen and MA on platelets. In my opinion, presence of shortened R should be highlighted
even if the retrospective design of the study does not allow comprehensive interpretation of
this result. Measurement of coagulation factors may reveal an explanation with implication in
clinical practice.
6) The manuscript needs extensive editing for grammar and syntax errors.
Title: Association of Thromboelastography Profile with Severity of Liver Cirrhosis and Portal
Venous System Thrombosis
Version: 1 Date: 21 Mar 2021
Reviewer:  Iliana Mani
Reviewer's report:
Dear Authors,
Cirrhosis has long been considered an acquired hemorrhagic disorder. However, in recent
years became clear that hemostasis in cirrhosis is rather “rebalanced”, as decreases in
procoagulant factors are accompanied by reduced levels of natural anticoagulants. Viscoelastic
tests significantly contributed to the better understanding of this complicated relationship,
providing information about the “in vivo” hemostatic procedure.
Thrombosis of the portal venous system occurs in a significant proportion of cirrhotic patients,
been more frequent in the advanced stages of liver disease. Although it is a well-known
complication, issues in regard to prognostic factors for its development, appropriate treatment
and duration of treatment are still under debate.
The current study is of great interest as it could improve our understanding about the
characteristics of hemostasis of patients presenting with portal venous system thrombosis and
subsequently to contribute to the better treatment or even prophylaxis of the vulnerable patients.
Major comments:
1) Authors should explain briefly the phases of hemostasis expressed by the variables of TEG
under study as well as the conventional coagulation factor(s) that are involved in each phase.
2) Fibrinogen is a key element for hemostasis. In TEG, its impairment leads to alternations both
of K and a-angle. Authors should mention levels of fibrinogen and study its correlation with
TEG parameters.
3) Authors should provide more information about the selection of criteria used to characterize
hypercoagulability as there is great discrepancy among the different studies and I did not find
a universal definition in regard to TEG.
4) A comparison between proportion of patients with values under or above the reference limit
would be significantly more informative than the comparison of median values between the
subgroups of interest.
5) Page 11, lines 221-223. R variable reflects the initiation of clot formation and is highly
dependent on coagulation factors. Both qualitative and quantitative platelets’ abnormalities are
accompanied by normal or near normal R. On the contrary, K and a angle are dependent mainly
on fibrinogen and MA on platelets. In my opinion, presence of shortened R should be highlighted
even if the retrospective design of the study does not allow comprehensive interpretation of
this result. Measurement of coagulation factors may reveal an explanation with implication in
clinical practice.
6) The manuscript needs extensive editing for grammar and syntax errors.
Please review this paper.
user
Title: Association of Thromboelastography Profile with Severity of Liver Cirrhosis and Portal
Venous System Thrombosis
Version: 1 Date: 21 Mar 2021
Reviewer:  Iliana Mani
Reviewer's report:
Dear Authors,
Cirrhosis has long been considered an acquired hemorrhagic disorder. However, in recent
years became clear that hemostasis in cirrhosis is rather “rebalanced”, as decreases in
procoagulant factors are accompanied by reduced levels of natural anticoagulants. Viscoelastic
tests significantly contributed to the better understanding of this complicated relationship,
providing information about the “in vivo” hemostatic procedure.
Thrombosis of the portal venous system occurs in a significant proportion of cirrhotic patients,
been more frequent in the advanced stages of liver disease. Although it is a well-known
complication, issues in regard to prognostic factors for its development, appropriate treatment
and duration of treatment are still under debate.
The current study is of great interest as it could improve our understanding about the
characteristics of hemostasis of patients presenting with portal venous system thrombosis and
subsequently to contribute to the better treatment or even prophylaxis of the vulnerable patients.
Major comments:
1) Authors should explain briefly the phases of hemostasis expressed by the variables of TEG
under study as well as the conventional coagulation factor(s) that are involved in each phase.
2) Fibrinogen is a key element for hemostasis. In TEG, its impairment leads to alternations both
of K and a-angle. Authors should mention levels of fibrinogen and study its correlation with
TEG parameters.
3) Authors should provide more information about the selection of criteria used to characterize
hypercoagulability as there is great discrepancy among the different studies and I did not find
a universal definition in regard to TEG.
4) A comparison between proportion of patients with values under or above the reference limit
would be significantly more informative than the comparison of median values between the
subgroups of interest.
5) Page 11, lines 221-223. R variable reflects the initiation of clot formation and is highly
dependent on coagulation factors. Both qualitative and quantitative platelets’ abnormalities are
accompanied by normal or near normal R. On the contrary, K and a angle are dependent mainly
on fibrinogen and MA on platelets. In my opinion, presence of shortened R should be highlighted
even if the retrospective design of the study does not allow comprehensive interpretation of
this result. Measurement of coagulation factors may reveal an explanation with implication in
clinical practice.
6) The manuscript needs extensive editing for grammar and syntax errors.
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