Review for 10.1186/s12876-025-03739-9 (2025)

Title: Phosphatidylserine induce thrombotic tendency and liver damage in obstructive jaundice
Version: 1 Date: 28 Jan 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-While tissue factor (TF) is briefly mentioned as playing a role in cholestasis-related
coagulopathy, it could be clearer whether TF expression is being directly studied in this research
or if it is being used as background information. If TF's role is not a focus of the current study,
it might be worth clarifying this point to avoid confusion.
-The introduction discusses the association of PS exposure with coagulation activation but
does not go into much detail regarding the molecular mechanisms involved. A more in-depth
explanation of how PS exposure leads to activation of the coagulation pathways (e.g., the
intrinsic/extrinsic pathways, prothrombinase complex formation) would strengthen the rationale
for studying PS in this context.
-It might be helpful to mention other possible contributors to coagulopathy in OJ, such as
elevated bilirubin, liver dysfunction, or inflammatory markers. This would further emphasize
the novelty of focusing on PS and its potential to serve as a central mechanistic link.
-The preparation of unconjugated bilirubin (UCB) is described in detail, but it would be helpful
to clarify the rationale behind the chosen concentrations (25, 50, 100 µM) and the significance
of the molar ratios of bilirubin to albumin. What is the expected physiological relevance of these
concentrations in the context of OJ? Adding this rationale would strengthen the experimental
design.
-The procedure for isolating microparticles (MPs) is clear, but the subsequent flow cytometry
analysis could be expanded. Specifically, it would be helpful to include more details on how the
MPs are quantified, particularly since MPs are being compared across different groups. A brief
explanation of how the MPs are counted (e.g., flow cytometric thresholding for MPs vs. larger
cells) would enhance reproducibility.
-The methods mention the use of lactadherin to inhibit PS-mediated procoagulant activity. It
might be useful to explain the expected outcome of lactadherin inhibition more clearly. For
example, will lactadherin reduce thrombin generation, and by what mechanism? This detail
could help readers understand the therapeutic potential of lactadherin more fully.
-The mouse BDL model is well-described, but it would be helpful to provide more context on
the expected outcomes of lactadherin treatment in the animal model. Is there a hypothesis about
how lactadherin might impact liver injury or coagulopathy in the BDL mice, and what specific
markers will be used to evaluate the effects?
-While the authors present a compelling narrative connecting PS exposure to hypercoagulability,
some aspects of the mechanistic pathways could be further clarified. For instance, the exact
molecular processes by which PS exposure on MPs and BCs leads to enhanced thrombin
generation could be more explicitly described. A deeper exploration into how PS facilitates the
prothrombinase complex assembly would enhance the biological relevance of the study.
-The study highlights a key finding that platelets in OJ patients exhibit PS exposure despite a
lower overall platelet count. The discussion briefly touches on enhanced splenic sequestration
and platelet accumulation in the hepatic sinusoidal space but could delve deeper into the
functional implications of this platelet dysfunction. Do these platelets become hyperreactive? Is
their altered behavior linked to increased thrombotic risk, or does this dysfunction represent an
earlier stage of platelet activation? Further discussion of the functional consequences of platelet
dysfunction in OJ could help strengthen the argument for targeting platelets in therapeutic
interventions.
-The role of hepatocytes in PS exposure is mentioned briefly but left unaddressed in terms
of mechanistic details. Given that hepatocyte apoptosis is a proposed feature of procoagulant
responses in liver disease, this should be more thoroughly integrated into the discussion. Are
hepatocyte-derived MPs contributing to the observed procoagulant state in OJ, or are they simply
a downstream effect? A more focused discussion on hepatocytes and their interaction with MPs,
especially in the context of cholestasis and hyperbilirubinemia, would further strengthen the
study’s conclusions.