Title: Prevalent Osteoporosis and Fracture Risk in Patients with Hepatic Cirrhosis: A Systematic
Review and Meta-analysis
Version: 0 Date: 08 Jan 2025
Reviewer's report:
This study included 21 studies through extensive database searches and systematically analyzed
the risk of osteoporosis and fractures in patients with cirrhosis. The results showed that patients
with cirrhosis have a higher risk of osteoporosis and fractures, suggesting the importance of
risk management and disease screening for patients with cirrhosis in the future. This study has
a reasonable design, clear logic, and appropriate analysis of relevant data, and has high clinical
significance.
However, this study still has the following problems to be solved:
1. The first two paragraphs of the background introduction should introduce osteoporosis and
cirrhosis separately. First, briefly introduce the characteristics of the two diseases, then explain
the potential relationship between them, and finally explain that the current research on this
relationship is still insufficient, thus leading to the necessity of this study.
2. Meta-analyses need to be excluded from the exclusion criteria.
3. Normally, patients with cirrhosis who have a higher average age should have an increased
risk of osteoporosis. Still, the opposite conclusion was obtained in this study#Meta-regression
revealed that studies with a higher mean age (p= 0.04) (Supplementary file 1: Figure S2) and
a higher prevalence of males (p= 0.03) (Supplementary file 1: Figure S3) had reduced odds of
osteoporosis in cirrhotic patients compared to controls.  Study design was found not to be a
possible source of heterogeneity (p>0.05).#. How does the author explain this difference?
4. Table 2 is not standardized and should be drawn in accordance with the standards of the three-
line table.
5. When conducting risk analysis in this study, several results showed excessive heterogeneity.
After removing individual studies, the heterogeneity was significantly reduced. Therefore, the
authors should focus on explaining in the discussion why the excluded studies can explain the
source of heterogeneity. For example, the study by Gonzalez-Calvin, Chen, Zheng et al.?
6. The authors could conduct subgroup analysis based on country (Western, Central Asia),
economic development level (developed, developing), and ethnicity, which would further enrich
the content of this study.
Title: Prevalent Osteoporosis and Fracture Risk in Patients with Hepatic Cirrhosis: A Systematic
Review and Meta-analysis
Version: 0 Date: 08 Jan 2025
Reviewer's report:
This study included 21 studies through extensive database searches and systematically analyzed
the risk of osteoporosis and fractures in patients with cirrhosis. The results showed that patients
with cirrhosis have a higher risk of osteoporosis and fractures, suggesting the importance of
risk management and disease screening for patients with cirrhosis in the future. This study has
a reasonable design, clear logic, and appropriate analysis of relevant data, and has high clinical
significance.
However, this study still has the following problems to be solved:
1. The first two paragraphs of the background introduction should introduce osteoporosis and
cirrhosis separately. First, briefly introduce the characteristics of the two diseases, then explain
the potential relationship between them, and finally explain that the current research on this
relationship is still insufficient, thus leading to the necessity of this study.
2. Meta-analyses need to be excluded from the exclusion criteria.
3. Normally, patients with cirrhosis who have a higher average age should have an increased
risk of osteoporosis. Still, the opposite conclusion was obtained in this study#Meta-regression
revealed that studies with a higher mean age (p= 0.04) (Supplementary file 1: Figure S2) and
a higher prevalence of males (p= 0.03) (Supplementary file 1: Figure S3) had reduced odds of
osteoporosis in cirrhotic patients compared to controls.  Study design was found not to be a
possible source of heterogeneity (p>0.05).#. How does the author explain this difference?
4. Table 2 is not standardized and should be drawn in accordance with the standards of the three-
line table.
5. When conducting risk analysis in this study, several results showed excessive heterogeneity.
After removing individual studies, the heterogeneity was significantly reduced. Therefore, the
authors should focus on explaining in the discussion why the excluded studies can explain the
source of heterogeneity. For example, the study by Gonzalez-Calvin, Chen, Zheng et al.?
6. The authors could conduct subgroup analysis based on country (Western, Central Asia),
economic development level (developed, developing), and ethnicity, which would further enrich
the content of this study.
Please review this paper.
user
Title: Prevalent Osteoporosis and Fracture Risk in Patients with Hepatic Cirrhosis: A Systematic
Review and Meta-analysis
Version: 0 Date: 08 Jan 2025
Reviewer's report:
This study included 21 studies through extensive database searches and systematically analyzed
the risk of osteoporosis and fractures in patients with cirrhosis. The results showed that patients
with cirrhosis have a higher risk of osteoporosis and fractures, suggesting the importance of
risk management and disease screening for patients with cirrhosis in the future. This study has
a reasonable design, clear logic, and appropriate analysis of relevant data, and has high clinical
significance.
However, this study still has the following problems to be solved:
1. The first two paragraphs of the background introduction should introduce osteoporosis and
cirrhosis separately. First, briefly introduce the characteristics of the two diseases, then explain
the potential relationship between them, and finally explain that the current research on this
relationship is still insufficient, thus leading to the necessity of this study.
2. Meta-analyses need to be excluded from the exclusion criteria.
3. Normally, patients with cirrhosis who have a higher average age should have an increased
risk of osteoporosis. Still, the opposite conclusion was obtained in this study#Meta-regression
revealed that studies with a higher mean age (p= 0.04) (Supplementary file 1: Figure S2) and
a higher prevalence of males (p= 0.03) (Supplementary file 1: Figure S3) had reduced odds of
osteoporosis in cirrhotic patients compared to controls.  Study design was found not to be a
possible source of heterogeneity (p>0.05).#. How does the author explain this difference?
4. Table 2 is not standardized and should be drawn in accordance with the standards of the three-
line table.
5. When conducting risk analysis in this study, several results showed excessive heterogeneity.
After removing individual studies, the heterogeneity was significantly reduced. Therefore, the
authors should focus on explaining in the discussion why the excluded studies can explain the
source of heterogeneity. For example, the study by Gonzalez-Calvin, Chen, Zheng et al.?
6. The authors could conduct subgroup analysis based on country (Western, Central Asia),
economic development level (developed, developing), and ethnicity, which would further enrich
the content of this study.
assistant