Reviewer ’s report  
 
Title: Usefulness of Ascitic Fluid Lactoferrin Levels in Patients with Liver Cirrhosis  
 
Version: 0 Date: 10 Jul 2016  
 
Reviewer: YVES HORSMANS  
 
Reviewer's report:  
 
Sang Soo Lee et al. describe the usefulness of Ascitic Fluid Lactoferrin Levels in Patients with 
Liver Cirrhosis.  In fact, they study the potential place of lactoferrrin in two situations: cirrhotics 
with SBP and cirrhorics with HCC.  
They found that "ascitic fluid lactoferrin level can be a useful diagnostic tool to identify SBP, 
with a sensitivity and specificity for a cut -off level of 51.4 ng/mL of 95.8% and 74.4%, 
respectively. Moreover, the incidence of HCC in the 78 patients without  SBP was significantly 
higher in patients with high ascitic fluid lactoferrin levels (≥35 ng/mL) than in those with low 
ascitic fluid lactoferrin level (<35 ng/mL).  Elevated ascitic fluid lactoferrin level without SBP 
may be indicative of a developing hep atocellular carcinoma."  
 
There are interesting data but this study suffers from major drawbacks:  
1. the authors do not justify the interest to determine lactoferrin in case of SBP since they use 
the classical definition of SBP which is a PMN count ≥ 250 ce lls/mm in ascitic fluid with or 
without a positive ascitic fluid or blood culture. Which is the interest to add the determination 
of ascitic lactoferrin level if PMN count is ≥ 250 cells/mm ?  Moreover, since they found that 
this determination is significa ntly correlated with inflammatory markers including WBC, 
PMN and CRP levels, which is the interest to determine ascitic lactoferrin level in 
comparison to these simple, easy availble inflammatory markers ?  
2. Similarly, the authors describe a higher incide nce of HCC in case of elevated ascitic 
lactoferrin level but which is the clinical interest ?  Do we have to ask more frequently liver 
ultrasound exams in these patients or other liver radiological exams ?  
Are the methods appropriate and well described?  
If not, please specify what is required in your commen ts 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.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please expla in in your comments to the authors.  
 
No 
 
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  
assessme nt in your comments to the editors.  
 
I recommend additional statistical review  
 
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 publi cation 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 curr ently 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 y es to any, please give details below.  
 
No conflict of interest nor receiving reimburssments... in relation with this manuscript  
 
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 lice nse ( 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 po licy of the journal  
Reviewer ’s report  
 
Title: Usefulness of Ascitic Fluid Lactoferrin Levels in Patients with Liver Cirrhosis  
 
Version: 0 Date: 10 Jul 2016  
 
Reviewer: YVES HORSMANS  
 
Reviewer's report:  
 
Sang Soo Lee et al. describe the usefulness of Ascitic Fluid Lactoferrin Levels in Patients with 
Liver Cirrhosis.  In fact, they study the potential place of lactoferrrin in two situations: cirrhotics 
with SBP and cirrhorics with HCC.  
They found that "ascitic fluid lactoferrin level can be a useful diagnostic tool to identify SBP, 
with a sensitivity and specificity for a cut -off level of 51.4 ng/mL of 95.8% and 74.4%, 
respectively. Moreover, the incidence of HCC in the 78 patients without  SBP was significantly 
higher in patients with high ascitic fluid lactoferrin levels (≥35 ng/mL) than in those with low 
ascitic fluid lactoferrin level (<35 ng/mL).  Elevated ascitic fluid lactoferrin level without SBP 
may be indicative of a developing hep atocellular carcinoma."  
 
There are interesting data but this study suffers from major drawbacks:  
1. the authors do not justify the interest to determine lactoferrin in case of SBP since they use 
the classical definition of SBP which is a PMN count ≥ 250 ce lls/mm in ascitic fluid with or 
without a positive ascitic fluid or blood culture. Which is the interest to add the determination 
of ascitic lactoferrin level if PMN count is ≥ 250 cells/mm ?  Moreover, since they found that 
this determination is significa ntly correlated with inflammatory markers including WBC, 
PMN and CRP levels, which is the interest to determine ascitic lactoferrin level in 
comparison to these simple, easy availble inflammatory markers ?  
2. Similarly, the authors describe a higher incide nce of HCC in case of elevated ascitic 
lactoferrin level but which is the clinical interest ?  Do we have to ask more frequently liver 
ultrasound exams in these patients or other liver radiological exams ?  
Are the methods appropriate and well described?  
If not, please specify what is required in your commen ts 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.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please expla in in your comments to the authors.  
 
No 
 
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  
assessme nt in your comments to the editors.  
 
I recommend additional statistical review  
 
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 publi cation 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 curr ently 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 y es to any, please give details below.  
 
No conflict of interest nor receiving reimburssments... in relation with this manuscript  
 
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 lice nse ( 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 po licy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Usefulness of Ascitic Fluid Lactoferrin Levels in Patients with Liver Cirrhosis  
 
Version: 0 Date: 10 Jul 2016  
 
Reviewer: YVES HORSMANS  
 
Reviewer's report:  
 
Sang Soo Lee et al. describe the usefulness of Ascitic Fluid Lactoferrin Levels in Patients with 
Liver Cirrhosis.  In fact, they study the potential place of lactoferrrin in two situations: cirrhotics 
with SBP and cirrhorics with HCC.  
They found that "ascitic fluid lactoferrin level can be a useful diagnostic tool to identify SBP, 
with a sensitivity and specificity for a cut -off level of 51.4 ng/mL of 95.8% and 74.4%, 
respectively. Moreover, the incidence of HCC in the 78 patients without  SBP was significantly 
higher in patients with high ascitic fluid lactoferrin levels (≥35 ng/mL) than in those with low 
ascitic fluid lactoferrin level (<35 ng/mL).  Elevated ascitic fluid lactoferrin level without SBP 
may be indicative of a developing hep atocellular carcinoma."  
 
There are interesting data but this study suffers from major drawbacks:  
1. the authors do not justify the interest to determine lactoferrin in case of SBP since they use 
the classical definition of SBP which is a PMN count ≥ 250 ce lls/mm in ascitic fluid with or 
without a positive ascitic fluid or blood culture. Which is the interest to add the determination 
of ascitic lactoferrin level if PMN count is ≥ 250 cells/mm ?  Moreover, since they found that 
this determination is significa ntly correlated with inflammatory markers including WBC, 
PMN and CRP levels, which is the interest to determine ascitic lactoferrin level in 
comparison to these simple, easy availble inflammatory markers ?  
2. Similarly, the authors describe a higher incide nce of HCC in case of elevated ascitic 
lactoferrin level but which is the clinical interest ?  Do we have to ask more frequently liver 
ultrasound exams in these patients or other liver radiological exams ?  
Are the methods appropriate and well described?  
If not, please specify what is required in your commen ts 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.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please expla in in your comments to the authors.  
 
No 
 
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  
assessme nt in your comments to the editors.  
 
I recommend additional statistical review  
 
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 publi cation 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 curr ently 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 y es to any, please give details below.  
 
No conflict of interest nor receiving reimburssments... in relation with this manuscript  
 
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 lice nse ( 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 po licy of the journal  
assistant