Reviewer’s report
Title: 
Ambulatory end-stage liver disease in Ghana; patient profile and utility of
alpha fetoprotein and aspartate aminotransferase - platelet ratio index.
Version: 
1 
Date: 
26 Apr 2020
Reviewer's report:
The results communicated in this paper are not absolutely new. However there
are only limited data from Ghana concerning epidemiology and socioeconomic
characteristics of patients with end stage liver disease (ESLD). Therefore the
authors have to be congratulated to have collected these important data, which
show, that diagnosis and treatment of patients with ESLD in Ghana has to be
improved urgently.
However I have a few concerns:
The "Gold Standard" for diagnosis of cirrhosis in this paper seems to have been
ultrasound - no liver biopsies and no elastography was performed. Therefore it
might well be, that the proportion of patients with CHILD A cirrhosis has been
underestimated, and so - from a scientific point of view - it is problematic to
conclude that most cirrhotic patients presented with decompensated cirrhosis.
Despite this fact I am sure that this conclusion is true - however, the problem of
a potential underestimation of the number of CHILD A cirrhotics should be
discussed (for example under the heading "limitations" in the chapter
"discussion".
Diagnosis of HCC was only based on ultrasound and it seems that no imaging
with intravenous contrast material was done. This may decrease sensitivity and
specificity of the diagnosis of HCC. I assume that these investigations could not
be done because of financial restrictions - but this fact, too should be discussed
as a limitation of the study.
In table 3 the specificity of AFP testing is reported under the heading "All HCC".
According to my understanding the specificity of a method can only be assessed
in a population NOT affected by the disease (in this case in NON-HCC patients).
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review is recommended, please specify what aspects
require further assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
no conflicts of interest
I agree to the open peer review policy of the journal. I understand that my name
will be included on my report to the authors and, if the manuscript is accepted
for publication, my named report including any attachments I upload will be
posted on the website along with the authors' responses. I agree for my report to
be made available under an Open Access Creative Commons CC-BY license
(
http://creativecommons.org/licenses/by/4.0/
). I understand that any comments
which I do not wish to be included in my named report can be included as
confidential comments to the editors, which will not be published.
I agree to the open peer review policy of the journal
Reviewer’s report
Title: 
Ambulatory end-stage liver disease in Ghana; patient profile and utility of
alpha fetoprotein and aspartate aminotransferase - platelet ratio index.
Version: 
1 
Date: 
26 Apr 2020
Reviewer's report:
The results communicated in this paper are not absolutely new. However there
are only limited data from Ghana concerning epidemiology and socioeconomic
characteristics of patients with end stage liver disease (ESLD). Therefore the
authors have to be congratulated to have collected these important data, which
show, that diagnosis and treatment of patients with ESLD in Ghana has to be
improved urgently.
However I have a few concerns:
The "Gold Standard" for diagnosis of cirrhosis in this paper seems to have been
ultrasound - no liver biopsies and no elastography was performed. Therefore it
might well be, that the proportion of patients with CHILD A cirrhosis has been
underestimated, and so - from a scientific point of view - it is problematic to
conclude that most cirrhotic patients presented with decompensated cirrhosis.
Despite this fact I am sure that this conclusion is true - however, the problem of
a potential underestimation of the number of CHILD A cirrhotics should be
discussed (for example under the heading "limitations" in the chapter
"discussion".
Diagnosis of HCC was only based on ultrasound and it seems that no imaging
with intravenous contrast material was done. This may decrease sensitivity and
specificity of the diagnosis of HCC. I assume that these investigations could not
be done because of financial restrictions - but this fact, too should be discussed
as a limitation of the study.
In table 3 the specificity of AFP testing is reported under the heading "All HCC".
According to my understanding the specificity of a method can only be assessed
in a population NOT affected by the disease (in this case in NON-HCC patients).
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review is recommended, please specify what aspects
require further assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
no conflicts of interest
I agree to the open peer review policy of the journal. I understand that my name
will be included on my report to the authors and, if the manuscript is accepted
for publication, my named report including any attachments I upload will be
posted on the website along with the authors' responses. I agree for my report to
be made available under an Open Access Creative Commons CC-BY license
(
http://creativecommons.org/licenses/by/4.0/
). I understand that any comments
which I do not wish to be included in my named report can be included as
confidential comments to the editors, which will not be published.
I agree to the open peer review policy of the journal
Please review this paper.
user
Reviewer’s report
Title: 
Ambulatory end-stage liver disease in Ghana; patient profile and utility of
alpha fetoprotein and aspartate aminotransferase - platelet ratio index.
Version: 
1 
Date: 
26 Apr 2020
Reviewer's report:
The results communicated in this paper are not absolutely new. However there
are only limited data from Ghana concerning epidemiology and socioeconomic
characteristics of patients with end stage liver disease (ESLD). Therefore the
authors have to be congratulated to have collected these important data, which
show, that diagnosis and treatment of patients with ESLD in Ghana has to be
improved urgently.
However I have a few concerns:
The "Gold Standard" for diagnosis of cirrhosis in this paper seems to have been
ultrasound - no liver biopsies and no elastography was performed. Therefore it
might well be, that the proportion of patients with CHILD A cirrhosis has been
underestimated, and so - from a scientific point of view - it is problematic to
conclude that most cirrhotic patients presented with decompensated cirrhosis.
Despite this fact I am sure that this conclusion is true - however, the problem of
a potential underestimation of the number of CHILD A cirrhotics should be
discussed (for example under the heading "limitations" in the chapter
"discussion".
Diagnosis of HCC was only based on ultrasound and it seems that no imaging
with intravenous contrast material was done. This may decrease sensitivity and
specificity of the diagnosis of HCC. I assume that these investigations could not
be done because of financial restrictions - but this fact, too should be discussed
as a limitation of the study.
In table 3 the specificity of AFP testing is reported under the heading "All HCC".
According to my understanding the specificity of a method can only be assessed
in a population NOT affected by the disease (in this case in NON-HCC patients).
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you
recommend an additional statistical review?
If an additional statistical review is recommended, please specify what aspects
require further assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or
salary from an organisation that may in any way gain or lose financially
from the publication of this manuscript, either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way
gain or lose financially from the publication of this manuscript, either now
or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this
paper?
If you can answer no to all of the above, write 'I declare that I have no competing
interests' below. If your reply is yes to any, please give details below.
no conflicts of interest
I agree to the open peer review policy of the journal. I understand that my name
will be included on my report to the authors and, if the manuscript is accepted
for publication, my named report including any attachments I upload will be
posted on the website along with the authors' responses. I agree for my report to
be made available under an Open Access Creative Commons CC-BY license
(
http://creativecommons.org/licenses/by/4.0/
). I understand that any comments
which I do not wish to be included in my named report can be included as
confidential comments to the editors, which will not be published.
I agree to the open peer review policy of the journal
assistant