Review for 10.1186/s12876-020-01581-9 (2020)

Reviewer’s report
Title: 
Ambulatory end-stage liver disease in Ghana; patient profile and utility of
alpha fetoprotein and aspartate aminotransferase - platelet ratio index.
Version: 
1 
Date: 
21 Jun 2020
Reviewer's report:
I want to congratulate Dr. Nartey et al. on their study on clinical patient profiles
and AFP levels of outpatients with end-stage liver disease in Ghana. In their
cross-sectional study, the authors compared clinical presentation and AFP levels
of patients with HCC to patients with liver cirrhosis and a control group with
chronic hepatitis B infection without signs of advanced liver disease. The
manuscript is very well-written and straight-forward, and the statistical methods
are adequate. In their study, the authors identified a high prevalence of HBV
especially in HCC patients, who presented at a very young age and in very
advanced stages. The study further highlighted that current international
recommendations, i.e. a diagnostic cut-off of AFP >400ng/mL or an APRI score
of >2, appear to be insufficient for the screening of HCC/ACLD, as the results
revealed very low sensitivity at these thresholds. 
I only have one major question to the authors:
1.) It appears that radiological exams were not performed in every patient
(according to the Methods section). Considering that AFP is only secreted in
approx. 50-60% of HCC, how were AFP-negative HCC cases diagnosed? Was
an ultrasound exam performed in every patient with a suspicion of HCC and low
AFP? It is remarkable that AFP appears to be more prevalent in early HCC
diagnosis than in late HCC, indicating potential diagnostic bias.
Minor: 
1.) Lines 61-62, sentence "In 2016, there were 1 million incident cases of liver
cancer, and 829,000 deaths"; the authors may specify whether these numbers are
referring to world-wide cases or sub-saharan countries for context.
2.) The authors may emphasize the prospective nature of this study in the
Methods section.
3.) If possible, the authors should add the proportion of patients under HBV
treatment at time of presentation to the patient characteristics, considering that
HBV treatment may lower AFP levels.
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No
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
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authors.
Yes
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Yes
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recommend an additional statistical review?
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require further assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
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Acceptable
Declaration of competing interests
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Potential conflicts of interest: Speaker honoraria BMS; institutional financial
support from Medis, Cook medical, W.L. Gore and associates; travel support
Roche, Gilead, BMS, Abbvie (>3 years prior to date).
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