Title: Sleep disturbance in patients with cirrhosis and transjugular intrahepatic portosystemic
shunt
Version: 3 Date: 25 Aug 2024
Reviewer:  Narayan Dharel
Reviewer's report:
Zhao et al reports on SD among patients with  cirrhosis post TIPS in a small nonrandomized
single center study among 119 patients who underwent TIPS between August 2018 and
November 2019 in West China Hospital.
They used the standardized PSQI to assess sleep quality, and West Haven Criteria to define HE.
They assessed these patients 1 month prior to TIPS and then at undefined time points ? post TIPS
up to 12 months after TIPS. Some patients were followed for up to 24 months per their report.
They excluded 46 patients who reported SD symptoms prior to TIPS. Among 73 post TIPS
patients who did not have SD symptoms 1 month prior to TIPS, 19 developed SD symptoms
post TIPS with median onset at day 67. Of those 73 patients, 20 also developed symptoms of
OHE and 28 showed symptoms of MHE.  They reported no patients were lost to median follow
up of 18mo (12-24 m range).
They do not clearly state how often did they check for SD post TIPS, e.g.? every month or one
time? or they just followed the charts to see if patients were diagnosed w SD.
It does not seem they tried to correlate as to what could have triggered SD post TIPS. Ammonia
was in the past reported to correlate with SD. Did they check ammonia level ? If show, was there
any correlation? It would have been nice to see if a biochemical marker would correlate with
SD, particularly because many patients who had SD spontaneously improved. Wonder if they
improved because their MHE or ammonia improved with lactulose?
How often they assessed SD post TIPS? At what interval? Needs further clarification.
Did they check ammonia levels and was there any correlation with SD?
What is their explanation of those 9 of 13 patients whose SD improved without any intervention?
Minor comments:
TIPS needs to  be spelled out the first time it was mentioned at the first para of abstract,
background section.
Method does not specify at what points of time SD was assessed after TIPS
Not clear on what basis decisions were made to treat vs observe SD
Not mentioned if they tested Ammonia post TIPS and if it correlated
Table title will look better  on the top than at the bottoms.
Title: Sleep disturbance in patients with cirrhosis and transjugular intrahepatic portosystemic
shunt
Version: 3 Date: 25 Aug 2024
Reviewer:  Narayan Dharel
Reviewer's report:
Zhao et al reports on SD among patients with  cirrhosis post TIPS in a small nonrandomized
single center study among 119 patients who underwent TIPS between August 2018 and
November 2019 in West China Hospital.
They used the standardized PSQI to assess sleep quality, and West Haven Criteria to define HE.
They assessed these patients 1 month prior to TIPS and then at undefined time points ? post TIPS
up to 12 months after TIPS. Some patients were followed for up to 24 months per their report.
They excluded 46 patients who reported SD symptoms prior to TIPS. Among 73 post TIPS
patients who did not have SD symptoms 1 month prior to TIPS, 19 developed SD symptoms
post TIPS with median onset at day 67. Of those 73 patients, 20 also developed symptoms of
OHE and 28 showed symptoms of MHE.  They reported no patients were lost to median follow
up of 18mo (12-24 m range).
They do not clearly state how often did they check for SD post TIPS, e.g.? every month or one
time? or they just followed the charts to see if patients were diagnosed w SD.
It does not seem they tried to correlate as to what could have triggered SD post TIPS. Ammonia
was in the past reported to correlate with SD. Did they check ammonia level ? If show, was there
any correlation? It would have been nice to see if a biochemical marker would correlate with
SD, particularly because many patients who had SD spontaneously improved. Wonder if they
improved because their MHE or ammonia improved with lactulose?
How often they assessed SD post TIPS? At what interval? Needs further clarification.
Did they check ammonia levels and was there any correlation with SD?
What is their explanation of those 9 of 13 patients whose SD improved without any intervention?
Minor comments:
TIPS needs to  be spelled out the first time it was mentioned at the first para of abstract,
background section.
Method does not specify at what points of time SD was assessed after TIPS
Not clear on what basis decisions were made to treat vs observe SD
Not mentioned if they tested Ammonia post TIPS and if it correlated
Table title will look better  on the top than at the bottoms.
Please review this paper.
user
Title: Sleep disturbance in patients with cirrhosis and transjugular intrahepatic portosystemic
shunt
Version: 3 Date: 25 Aug 2024
Reviewer:  Narayan Dharel
Reviewer's report:
Zhao et al reports on SD among patients with  cirrhosis post TIPS in a small nonrandomized
single center study among 119 patients who underwent TIPS between August 2018 and
November 2019 in West China Hospital.
They used the standardized PSQI to assess sleep quality, and West Haven Criteria to define HE.
They assessed these patients 1 month prior to TIPS and then at undefined time points ? post TIPS
up to 12 months after TIPS. Some patients were followed for up to 24 months per their report.
They excluded 46 patients who reported SD symptoms prior to TIPS. Among 73 post TIPS
patients who did not have SD symptoms 1 month prior to TIPS, 19 developed SD symptoms
post TIPS with median onset at day 67. Of those 73 patients, 20 also developed symptoms of
OHE and 28 showed symptoms of MHE.  They reported no patients were lost to median follow
up of 18mo (12-24 m range).
They do not clearly state how often did they check for SD post TIPS, e.g.? every month or one
time? or they just followed the charts to see if patients were diagnosed w SD.
It does not seem they tried to correlate as to what could have triggered SD post TIPS. Ammonia
was in the past reported to correlate with SD. Did they check ammonia level ? If show, was there
any correlation? It would have been nice to see if a biochemical marker would correlate with
SD, particularly because many patients who had SD spontaneously improved. Wonder if they
improved because their MHE or ammonia improved with lactulose?
How often they assessed SD post TIPS? At what interval? Needs further clarification.
Did they check ammonia levels and was there any correlation with SD?
What is their explanation of those 9 of 13 patients whose SD improved without any intervention?
Minor comments:
TIPS needs to  be spelled out the first time it was mentioned at the first para of abstract,
background section.
Method does not specify at what points of time SD was assessed after TIPS
Not clear on what basis decisions were made to treat vs observe SD
Not mentioned if they tested Ammonia post TIPS and if it correlated
Table title will look better  on the top than at the bottoms.
assistant