Title: Treatment and outcome of hepatorenal syndrome in Japan: A retrospective cohort study
using a national inpatient database
Version: 2 Date: 08 Apr 2023
Reviewer's report:
In this manuscript, Okushin et al. reported the nationwide study of the clinical characteristics,
treatment details, and mortality of Hepatorenal syndrome (HRS) by using The Japanese
Diagnosis Procedure Combination database. The authors concluded that HRS in Japan has a
high mortality rate. Although noradrenaline is recommended in Japanese clinical guidelines,
dopamine was more frequently used as a vasoconstrictor in clinical practice.
This paper is interesting and useful contribution. On the other hand, I think that this paper still
has some problems as indicated below. There are several comments to be addressed.
Major comments
1. The majority of HRS-acute kidney injury (AKI) episodes are precursor by acute events. It
is important to identify and appropriately treat all precipitating symptoms. Complications of
bacterial infections such as spontaneous bacterial peritonitis in patients with cirrhosis are a
high risk factor for the development of HRS. Bacterial infections can induce AKI due to the
production of excessive inflammatory cytokines.
Would it be possible to add results and discussion regarding the presence or absence of SBP,
other infections, and antibiotic therapy?
2. The authors discuss the possibility that many HRS patients in Japan do not receive specific and
intensive treatment at the appropriate time. Would the authors be able to provide some insight
into the reasons for this?
3. Traditional diagnostic criteria for HRS have required a serum creatinine level greater than
1.5 mg/dL and have not taken into account the degree or rapidity of increase from baseline
values. In the Evidence-based clinical practice guidelines for liver cirrhosis 2020, HRS-AKI
meets the diagnostic criteria for AKI in patients with cirrhosis proposed by the International
Club of Ascites. Would these diagnostic criteria allow for earlier diagnosis? Can the authors
describe their discussion of it?
Title: Treatment and outcome of hepatorenal syndrome in Japan: A retrospective cohort study
using a national inpatient database
Version: 2 Date: 08 Apr 2023
Reviewer's report:
In this manuscript, Okushin et al. reported the nationwide study of the clinical characteristics,
treatment details, and mortality of Hepatorenal syndrome (HRS) by using The Japanese
Diagnosis Procedure Combination database. The authors concluded that HRS in Japan has a
high mortality rate. Although noradrenaline is recommended in Japanese clinical guidelines,
dopamine was more frequently used as a vasoconstrictor in clinical practice.
This paper is interesting and useful contribution. On the other hand, I think that this paper still
has some problems as indicated below. There are several comments to be addressed.
Major comments
1. The majority of HRS-acute kidney injury (AKI) episodes are precursor by acute events. It
is important to identify and appropriately treat all precipitating symptoms. Complications of
bacterial infections such as spontaneous bacterial peritonitis in patients with cirrhosis are a
high risk factor for the development of HRS. Bacterial infections can induce AKI due to the
production of excessive inflammatory cytokines.
Would it be possible to add results and discussion regarding the presence or absence of SBP,
other infections, and antibiotic therapy?
2. The authors discuss the possibility that many HRS patients in Japan do not receive specific and
intensive treatment at the appropriate time. Would the authors be able to provide some insight
into the reasons for this?
3. Traditional diagnostic criteria for HRS have required a serum creatinine level greater than
1.5 mg/dL and have not taken into account the degree or rapidity of increase from baseline
values. In the Evidence-based clinical practice guidelines for liver cirrhosis 2020, HRS-AKI
meets the diagnostic criteria for AKI in patients with cirrhosis proposed by the International
Club of Ascites. Would these diagnostic criteria allow for earlier diagnosis? Can the authors
describe their discussion of it?
Please review this paper.
user
Title: Treatment and outcome of hepatorenal syndrome in Japan: A retrospective cohort study
using a national inpatient database
Version: 2 Date: 08 Apr 2023
Reviewer's report:
In this manuscript, Okushin et al. reported the nationwide study of the clinical characteristics,
treatment details, and mortality of Hepatorenal syndrome (HRS) by using The Japanese
Diagnosis Procedure Combination database. The authors concluded that HRS in Japan has a
high mortality rate. Although noradrenaline is recommended in Japanese clinical guidelines,
dopamine was more frequently used as a vasoconstrictor in clinical practice.
This paper is interesting and useful contribution. On the other hand, I think that this paper still
has some problems as indicated below. There are several comments to be addressed.
Major comments
1. The majority of HRS-acute kidney injury (AKI) episodes are precursor by acute events. It
is important to identify and appropriately treat all precipitating symptoms. Complications of
bacterial infections such as spontaneous bacterial peritonitis in patients with cirrhosis are a
high risk factor for the development of HRS. Bacterial infections can induce AKI due to the
production of excessive inflammatory cytokines.
Would it be possible to add results and discussion regarding the presence or absence of SBP,
other infections, and antibiotic therapy?
2. The authors discuss the possibility that many HRS patients in Japan do not receive specific and
intensive treatment at the appropriate time. Would the authors be able to provide some insight
into the reasons for this?
3. Traditional diagnostic criteria for HRS have required a serum creatinine level greater than
1.5 mg/dL and have not taken into account the degree or rapidity of increase from baseline
values. In the Evidence-based clinical practice guidelines for liver cirrhosis 2020, HRS-AKI
meets the diagnostic criteria for AKI in patients with cirrhosis proposed by the International
Club of Ascites. Would these diagnostic criteria allow for earlier diagnosis? Can the authors
describe their discussion of it?
assistant