Review for 10.1186/s12876-025-03772-8 (2025)

Title: Increased intra-abdominal pressure linked to worse long-term prognosis among patients
with orthotopic liver transplantation: A retrospective, observational study
Version: 2 Date: 29 Jan 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-While the background emphasizes the importance of IAP in postoperative monitoring, it could
benefit from more direct references to prior studies specifically on IAP and SOFA in liver
transplantation. This would strengthen the rationale for the study by providing evidence of
existing gaps.
-The background briefly mentions ACS but doesn't provide much detail on how it affects post-
OLT outcomes. A clearer explanation of how ACS ties into the prognosis of liver transplant
patients (in terms of organ failure, treatment complications, etc.) might better highlight the
relevance of the study.
-While the SOFA score assessment is mentioned, it would be beneficial to elaborate on the
criteria used for scoring daily. For instance, did the study use a fixed protocol for evaluating
SOFA, and was there any inter-rater variability? Clarifying this can enhance the reproducibility
and robustness of the methodology.
-The manuscript specifies that IAP was measured every 6 hours, but it would be helpful to
include information on how frequently IAP readings were taken during the early post-operative
period (e.g., first 48 hours). Were there any specific clinical triggers for measuring more
frequently?
-While the study establishes a relationship between IAP and mortality, the discussion could delve
deeper into the physiological mechanisms. For example, how does elevated IAP contribute to
multi-organ failure, particularly in the context of liver transplantation? Are there specific organ
systems (e.g., kidney, lungs) that are more vulnerable to high IAP post-OLT?
-In the discussion, the manuscript mentions that although the ICU mortality rate was higher in
patients with IAH, the difference was not statistically significant. It would be helpful to provide
more context or a brief hypothesis on why this might be the case. For instance:
.Could other critical factors (e.g., liver function failure, infection, or multi-organ dysfunction)
be contributing to the mortality risk in IAH patients?
.Are there specific subgroups of patients with IAH (e.g., primary vs. secondary IAH) that
could show different mortality trends in the ICU, which might explain the lack of statistical
significance?
-The study mentions 30-day and 1-year mortality, but the discussion could further elaborate
on how IAH influences long-term outcomes, such as liver function recovery, quality of life, or
the need for re-hospitalization. Are there additional mechanisms (e.g., liver graft dysfunction,
systemic inflammation) that IAH might exacerbate, leading to poorer long-term recovery?
-While the study discusses how the combination of IAH grading and SOFA enhances prognosis
prediction, it could benefit from a direct comparison to other established prognostic models
in liver transplantation, such as MELD (Model for End-Stage Liver Disease) or the liver
transplant-specific prognostic scores. The discussion could explore whether IAP and SOFA offer
a complementary advantage over these models or whether there’s redundancy in their predictive
capabilities.