Review for 10.1186/s12876-025-03628-1 (2025)

Title: Magnitude, Patterns, and Factors Associated with Liver Disease among Clinically
Suspected Clients in Eastern Ethiopia: Hidden Public Health Tragedy
Version: 4 Date: 21 Sep 2024
Reviewer:  Mohammad Amin Fallahzadeh
Reviewer's report:
The study investigates the prevalence and risk factors associated with liver disease among
388 clinically suspected patients at a public health facility in Dire Dawa, Eastern Ethiopia.
The findings reveal that 76% of participants were diagnosed with liver disease, predominantly
chronic liver disease (CLD) from non-viral (65.1%) and viral causes (34.9%). Key risk factors
identified include female sex, lower educational status, alcohol consumption, and khat chewing.
The research highlights significant public health concerns regarding liver disease in the region
and provides valuable insights into liver disease prevalence and associated risk factors in a
specific population, underscoring the need for targeted public health interventions. There are
some comments:
Major comments:
-In Methods, subject selection is not clear. Were the patients clinically suspected to have liver
disease based on the symptoms or were they screened initially based on other criteria and selected
only if they had symptoms? This needs to be clarified.
-Do authors have any data about the number of patients with established liver disease who were
excluded? This will be helpful to assess the magnitude of the liver disease if available.
-In sample size estimation, it is confusing that the prevalence of liver disease is presumed to be
50% but it is called rare later in the sentence. This needs further clarification.
-In sample size estimation, what are first and second objectives?
-Did the authors check other liver-related lab tests such as platelet count, bilirubin, Alkaline
phosphatase, serum albumin or PT/INR? If yes, this need to be mentioned in Methods.
-Variables in the study section of Methods: the authors previously mentioned that patients with
established CLD were excluded and here they mention that they were included (2nd sentence)?
-How did authors determine their criteria to define analytical liver injury?
-How did authors determine Fib-4 score >= 3.25 as the cutoff for advanced fibrosis?
-What normality plots and tests were used?
-How do authors differentiate chewing khat and habit of chewing khat?
-Authors need to be consistent about using AST/ALT or SGOT/SGLT.
-How do authors consider range of 0-56 to be normal for AST/ALT? Isn't 56 too high to be
normal?
-Authors' classification of form of liver disease needs to be modified. Do they mean etiology or
severity? They have a vague definition here.
-Authors should also mention other limitations such as their cross-sectional study design that
only provides associations and not causal relationships. Also, the reliance on self-reported data
for substance use and health history could introduce recall bias.
-The findings may not be generalizable to the broader population since the sample is limited
to one health facility. Consider discussing the implications of this limitation on the overall
conclusions.
-Consider discussing the longitudinal impacts of identified risk factors and potential preventive
strategies in future research.
Minor comments:
-In the abstract, there is no mention of the blood transfusion in Results section, but it's mentioned
in the conclusion. This needs to be unified to either present in both sections.
-Paragraph 2 of introduction: liver is not always enlarged in liver disease. Enlargement typically
refers to acute hepatitis state while in the chronic state of cirrhosis, it actually shrinks. This needs
to be clarified.
-Paragraph 3 of introduction: last sentence is redundant and repeat of the sentence prior to that.
-Paragraph 4 of introduction: did you mean 1.5% of the total disease burden? % is missing.
-Authors are encouraged to use update nomenclature such as MASLD or MASH rather than
NASLD or NASH.
-Can Author mention the total population of Ethiopia in the Study area section as well?
-Study area and period: 6th sentence, did you mean khat chewing instead of "chat chewing"?
-As khat is not a substance that is not commonly known all over the world, authors are
encouraged to provide further explanation about it in the Methods section.
-OPD needs to be spelled out before being used.
-Instead of liver function tests, authors are encouraged to use liver enzymes as they do not
actually measure the liver function.
-In the first sentence of Variables in the study of Methods, do they mean the dependent variable
was presence of liver disease?
-388 participants were interviewed or were approached for interview and 92% accepted?
-Did those 24% of participants have the symptoms but no objective marker of liver disease on
labs or US?
-Factores associated with ... Section:
Khat need to be added to chewing in the body of the Paragraph
Being male and attending higher education decreased or increased the risk of developing liver
disease?
-2nd paragraph of Discussion: did you mean MASLD instead of non-fatty liver disease?
-2nd paragraph Discussion; it should be noted that these numbers are from another study and
not the current study.
-5th paragraph of Discussion: It is also associated with ... ; what does "It" refer to?