Title: A dynamic model to predict early occurrence of acute kidney injury in ICU hospitalized
cirrhotic patients: A MIMIC database analysis
Version: 3 Date: 17 Jun 2024
Reviewer's report:
In this manuscript entitled “Development and Validation of a dynamic online nomogram
predicting acute kidney injury in critically ill patients with cirrhosis”, the authors developed a
nomogram for predicting acute kidney injury in patients with cirrhosis. While the topic is an
important point, there are some concerns which should be clarified.
Major comments
1. In the introduction, the authors explained that “there is no relevant research or clinical
prediction model for the risk assessment of AKI in ICU patients with liver cirrhosis” (page 4,
line 74 to 76). In addition, in the discussion, the authors emphasized that “there is no relevant
research or clinical prediction model for the risk assessment of AKI in ICU patients with liver
cirrhosis” (page 11, lines 235 to 237). However, this is not true because there is already a
publication with similar study design using the same database (please check: PMID: 36778740).
Therefore, the authors’ explanations can mislead the readers. The authors must modify the text
by citing the literature.
2. The authors explained that “Among the patients with AKI, only 28 patients (3.6%) had
AKI 7 days after admission. Considering the practical difficulty in predicting AKI later in
hospitalization based on admission data, AKI beyond 7 days was not included in the primary
outcome. ” (page 8, lines 167 to 170). The authors should explain this in the method section
and make the point clearer. In addition, since the authors analyzed AKI within seven days, the
mortality rate of mortality after seven days (in-hospital, 28 days, 90 days, 1 year) should be
deleted because this information is irrelevant to the study.
3. The authors should include albumin in data collection and analysis because albumin levels are
associated with AKI and albumin infusion is a basic treatment for AKI (please check: PMID:
34816016). In addition, presence of heart failure and medications for cirrhosis such as diuretics,
BCAA, lactulose, and rifaximin should also added in Table 1 because these variables can also
affect AKI development.
4. In the result section, the explanation for baseline characteristics is too wordy and difficult to
read (page 8, line 164 to page 10, line 202). The authors should delete irrelevant data and avoid
redundant explanations.
5. Death is a competing risk for AKI. If the authors have not used a model considering the
competing risk such as Fine-Gray analysis. This is a limitation of this study.
6. The authors developed a short-term AKI prediction model. However, a recent study shows
that longitudinal AKI development is also important issue. The authors should make a discussion
by citing this study (PMID: 38861012).
Minor comments
1. The authors should consider modifying the title because the current title is very similar to a
previous paper (please check: PMID: 36778740).
2. “Alcoholic cirrhosis” is an inappropriate explanation with stigma. Please use alcohol related
cirrhosis or alcohol associated cirrhosis.
3. The authors should clearly define the CKD in this study because they used this as an exclusion
criterion.
Title: A dynamic model to predict early occurrence of acute kidney injury in ICU hospitalized
cirrhotic patients: A MIMIC database analysis
Version: 3 Date: 17 Jun 2024
Reviewer's report:
In this manuscript entitled “Development and Validation of a dynamic online nomogram
predicting acute kidney injury in critically ill patients with cirrhosis”, the authors developed a
nomogram for predicting acute kidney injury in patients with cirrhosis. While the topic is an
important point, there are some concerns which should be clarified.
Major comments
1. In the introduction, the authors explained that “there is no relevant research or clinical
prediction model for the risk assessment of AKI in ICU patients with liver cirrhosis” (page 4,
line 74 to 76). In addition, in the discussion, the authors emphasized that “there is no relevant
research or clinical prediction model for the risk assessment of AKI in ICU patients with liver
cirrhosis” (page 11, lines 235 to 237). However, this is not true because there is already a
publication with similar study design using the same database (please check: PMID: 36778740).
Therefore, the authors’ explanations can mislead the readers. The authors must modify the text
by citing the literature.
2. The authors explained that “Among the patients with AKI, only 28 patients (3.6%) had
AKI 7 days after admission. Considering the practical difficulty in predicting AKI later in
hospitalization based on admission data, AKI beyond 7 days was not included in the primary
outcome. ” (page 8, lines 167 to 170). The authors should explain this in the method section
and make the point clearer. In addition, since the authors analyzed AKI within seven days, the
mortality rate of mortality after seven days (in-hospital, 28 days, 90 days, 1 year) should be
deleted because this information is irrelevant to the study.
3. The authors should include albumin in data collection and analysis because albumin levels are
associated with AKI and albumin infusion is a basic treatment for AKI (please check: PMID:
34816016). In addition, presence of heart failure and medications for cirrhosis such as diuretics,
BCAA, lactulose, and rifaximin should also added in Table 1 because these variables can also
affect AKI development.
4. In the result section, the explanation for baseline characteristics is too wordy and difficult to
read (page 8, line 164 to page 10, line 202). The authors should delete irrelevant data and avoid
redundant explanations.
5. Death is a competing risk for AKI. If the authors have not used a model considering the
competing risk such as Fine-Gray analysis. This is a limitation of this study.
6. The authors developed a short-term AKI prediction model. However, a recent study shows
that longitudinal AKI development is also important issue. The authors should make a discussion
by citing this study (PMID: 38861012).
Minor comments
1. The authors should consider modifying the title because the current title is very similar to a
previous paper (please check: PMID: 36778740).
2. “Alcoholic cirrhosis” is an inappropriate explanation with stigma. Please use alcohol related
cirrhosis or alcohol associated cirrhosis.
3. The authors should clearly define the CKD in this study because they used this as an exclusion
criterion.
Please review this paper.
user
Title: A dynamic model to predict early occurrence of acute kidney injury in ICU hospitalized
cirrhotic patients: A MIMIC database analysis
Version: 3 Date: 17 Jun 2024
Reviewer's report:
In this manuscript entitled “Development and Validation of a dynamic online nomogram
predicting acute kidney injury in critically ill patients with cirrhosis”, the authors developed a
nomogram for predicting acute kidney injury in patients with cirrhosis. While the topic is an
important point, there are some concerns which should be clarified.
Major comments
1. In the introduction, the authors explained that “there is no relevant research or clinical
prediction model for the risk assessment of AKI in ICU patients with liver cirrhosis” (page 4,
line 74 to 76). In addition, in the discussion, the authors emphasized that “there is no relevant
research or clinical prediction model for the risk assessment of AKI in ICU patients with liver
cirrhosis” (page 11, lines 235 to 237). However, this is not true because there is already a
publication with similar study design using the same database (please check: PMID: 36778740).
Therefore, the authors’ explanations can mislead the readers. The authors must modify the text
by citing the literature.
2. The authors explained that “Among the patients with AKI, only 28 patients (3.6%) had
AKI 7 days after admission. Considering the practical difficulty in predicting AKI later in
hospitalization based on admission data, AKI beyond 7 days was not included in the primary
outcome. ” (page 8, lines 167 to 170). The authors should explain this in the method section
and make the point clearer. In addition, since the authors analyzed AKI within seven days, the
mortality rate of mortality after seven days (in-hospital, 28 days, 90 days, 1 year) should be
deleted because this information is irrelevant to the study.
3. The authors should include albumin in data collection and analysis because albumin levels are
associated with AKI and albumin infusion is a basic treatment for AKI (please check: PMID:
34816016). In addition, presence of heart failure and medications for cirrhosis such as diuretics,
BCAA, lactulose, and rifaximin should also added in Table 1 because these variables can also
affect AKI development.
4. In the result section, the explanation for baseline characteristics is too wordy and difficult to
read (page 8, line 164 to page 10, line 202). The authors should delete irrelevant data and avoid
redundant explanations.
5. Death is a competing risk for AKI. If the authors have not used a model considering the
competing risk such as Fine-Gray analysis. This is a limitation of this study.
6. The authors developed a short-term AKI prediction model. However, a recent study shows
that longitudinal AKI development is also important issue. The authors should make a discussion
by citing this study (PMID: 38861012).
Minor comments
1. The authors should consider modifying the title because the current title is very similar to a
previous paper (please check: PMID: 36778740).
2. “Alcoholic cirrhosis” is an inappropriate explanation with stigma. Please use alcohol related
cirrhosis or alcohol associated cirrhosis.
3. The authors should clearly define the CKD in this study because they used this as an exclusion
criterion.
assistant