Review for 10.1186/s12876-023-02781-9 (2023)

Title: Angiotensin Receptor Blockers Might be Protective against Hepatic Steatosis after Liver
Transplantation
Version: 2 Date: 14 Mar 2023
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: I read with interest the manuscript evaluating the role of ARB in
post liver transplant recipients and the association with hepatic steatosis. The manuscript carries
novelty, as there is a lack of data regarding this.
REQUESTED REVISIONS:
Thank you for allowing me to read this interesting work by Eshraghian et al. The work is
certainly of importance to the readers; however, I have the following comments which I feel
will further strengthen this work.
1. Why was the cut off of 3 months of ARB used for this study? The authors should justify this
based on prior studies / experience, etc.
2. Results: The authors mentioned “In regression model, ARB use was associated with lower
likelihood of hepatic steatosis in liver transplant recipients (OR = 3.299, 95 % CI: 1.274- 8.541;
P = 0.014)”. To my understanding, if something has a lower incidence of occurring, then OR
should be below 1 to assume it is protective.
3. The authors presented table 1 where baseline comparison between steatosis vs. non-steatosis
patients is given. It is important to present baseline comparison between patients using ARB vs.
those not using it as well.
4. The authors mentioned that statins did not influence outcomes, but what about the use
of fibrates? It seemed that patients with NASH and steatosis had higher triglycerides levels
compared to those without. Can the authors evaluate this as well?
5. It is important to know the underlying etiology of liver cirrhosis for each group, i.e., ARB use
vs. non-ARB use and if subsequent use of ARB vs. non-ARB was associated with steatosis.
6. The authors failed to mention the use of alcohol prior to liver transplant vs. after.
7. Did the authors use any other form of non-invasive testing such as FIB4 panel, elastography,
etc. or invasive testing. i.e., liver biopsy to confirm their findings or was the data relied only
on ultrasound?
8. The authors mentioned the strengths of this study; however, it is equally important to mention
the main limitations of the study, the biggest being the retrospective nature of the study and
other being small sample size."