Dynamic Prognostication in Transplant Candidates with Acute-on-Chronic Liver Failure

Round 1

Reviewer 1 Report

I recommend acceptance in present form.

Author Response

Thank you.

Reviewer 2 Report

.

Author Response

Thank you.

Reviewer 3 Report

Introductory note:

My review has to be viewed in the context of my core background rooted in European hepatology; therefore, it is up to the editors to decide if they accept my comments, i.e. wish the article targeting also audience outside APASL. If it is APASL-directed-paper only, some of my comments can be ignored.

General comments:

1)topic (dynamic prognostication of ACLF) is well chosen, actual, hot.

2)even if the paper would be viewed as APASL-only, in the background / introduction section it should contain mentioning other definitions of ACLF (EASL-CLIF, NACSELD, consensus) and put APASL in their context. It will take few minutes to highlight the main differences. Also, authors should consider mentioning the urgent need to agree on the one universal definition.

3)authors have done a good work coming out with plethora of time-points / significant predictive variables, but for the hepatologists in clinical practice the take-home message would only be: "yes, ACLF is dynamic, and yes, if the patient's labs do not improve, it is worsening". But we know that already. The permutation of time points, variables, and odds ratios is rather messy. I suggest adding to the complete result a destillery: choosing one or two most significant predictive variables for each time point and formulate very clear very simple advice.

4)authors do not say what to do with such and such results: e.g. if at this and this timepoint this and this variable worsen, proceed to fast-track liver transplant, or to plasmapheresis. Also they should mention futility - if at this timepoint results are like that, consider switching to the palliative care. Some practical recommendations are needed what to do with results.

Special comments are aiming particularly at practical use of the results. It is very low at present, but can be achieved with the same results by paying attention to General comments, sorting-out the most valuable results, and their underscoring in re-formulated Discussion. Further suggestions are: 

5)try to sub classify patients to ACLF 1,2, and 3

6)the most important similar study from the West was that of Gustot et al in which they defined the "Severe early course" of ACLF. Their definition is immediately useful: if the patient stays at-, or progresses to grade X+ ACLF at day X, then ... Authors should refer to it briefly.

7)special attention should be paid to results on liver transplant, as to understand the results mean asking relatives to provide the split organ, or admit probability of loosing the relative: I suggest making clear comments - does your data help in recommending fast-track LT?

8)commenting on the ethiology is based on very low numbers, and should be de-emphasized

 

Author Response

Please see the attachment.

Thank you.

Author Response File: Author Response.docx

Round 2

Reviewer 3 Report

All the suggestions were appropriately reflected, text should be readable and useful for ACLF community both in the East and the West.