Title: Clinical significance of transjugular liver biopsy in acute liver failure – a real-world
analysis
Version: 4 Date: 19 Jun 2024
Reviewer's report:
The authors report a single center experience with TJLB in patients presenting with acute liver
failure.  Consistent with previous  reports the authors conclude that TJLB does not routinely
add significantly to the management of acute liver failure.  Unfortunately this report does not
present novel findings.
Minor Questions or Concerns:
1.  Given this is retrospective study, can the authors comment on why liver biopsies were
performed in cases where the diagnosis was overall certain?
2.  The authors report that in three cases of suspected and biopsy confirmed autoimmune hepatitis
the biopsy influenced management.  This deserves more explanation, the standard of care
for autoimmune hepatitis is immunosuppressive therapy, not clear how the biopsy influenced
management in these cases.
3.  The authors include two patients in Table 2 which the presumed ALF etiology was
"alcoholic" .  Alcohol does not cause acute liver failure.  It may result in severe liver dysfunction
in the context of severe alcohol associated hepatitis but this is a form of acute on chronic liver
failure and not ALF.  These patients should be removed from the analysis.
4.  The authors report 2 cases of indeterminate ALF that were confirmed as drug induced.  It
would be beneficial to the reader to understand what feature on biopsy confirmed drug induced
liver injury.  It is not common that pathology can so clearly identify DILI, it is more often a
diagnosis of clinical history and biopsy findings can support but rarely confirm this.
Title: Clinical significance of transjugular liver biopsy in acute liver failure – a real-world
analysis
Version: 4 Date: 19 Jun 2024
Reviewer's report:
The authors report a single center experience with TJLB in patients presenting with acute liver
failure.  Consistent with previous  reports the authors conclude that TJLB does not routinely
add significantly to the management of acute liver failure.  Unfortunately this report does not
present novel findings.
Minor Questions or Concerns:
1.  Given this is retrospective study, can the authors comment on why liver biopsies were
performed in cases where the diagnosis was overall certain?
2.  The authors report that in three cases of suspected and biopsy confirmed autoimmune hepatitis
the biopsy influenced management.  This deserves more explanation, the standard of care
for autoimmune hepatitis is immunosuppressive therapy, not clear how the biopsy influenced
management in these cases.
3.  The authors include two patients in Table 2 which the presumed ALF etiology was
"alcoholic" .  Alcohol does not cause acute liver failure.  It may result in severe liver dysfunction
in the context of severe alcohol associated hepatitis but this is a form of acute on chronic liver
failure and not ALF.  These patients should be removed from the analysis.
4.  The authors report 2 cases of indeterminate ALF that were confirmed as drug induced.  It
would be beneficial to the reader to understand what feature on biopsy confirmed drug induced
liver injury.  It is not common that pathology can so clearly identify DILI, it is more often a
diagnosis of clinical history and biopsy findings can support but rarely confirm this.
Please review this paper.
user
Title: Clinical significance of transjugular liver biopsy in acute liver failure – a real-world
analysis
Version: 4 Date: 19 Jun 2024
Reviewer's report:
The authors report a single center experience with TJLB in patients presenting with acute liver
failure.  Consistent with previous  reports the authors conclude that TJLB does not routinely
add significantly to the management of acute liver failure.  Unfortunately this report does not
present novel findings.
Minor Questions or Concerns:
1.  Given this is retrospective study, can the authors comment on why liver biopsies were
performed in cases where the diagnosis was overall certain?
2.  The authors report that in three cases of suspected and biopsy confirmed autoimmune hepatitis
the biopsy influenced management.  This deserves more explanation, the standard of care
for autoimmune hepatitis is immunosuppressive therapy, not clear how the biopsy influenced
management in these cases.
3.  The authors include two patients in Table 2 which the presumed ALF etiology was
"alcoholic" .  Alcohol does not cause acute liver failure.  It may result in severe liver dysfunction
in the context of severe alcohol associated hepatitis but this is a form of acute on chronic liver
failure and not ALF.  These patients should be removed from the analysis.
4.  The authors report 2 cases of indeterminate ALF that were confirmed as drug induced.  It
would be beneficial to the reader to understand what feature on biopsy confirmed drug induced
liver injury.  It is not common that pathology can so clearly identify DILI, it is more often a
diagnosis of clinical history and biopsy findings can support but rarely confirm this.
assistant