Reviewer ’s report  
 
Title: Number of Parity Is Associated with Low -Grade Albumin uria in Middle -Aged and Elderly 
Chinese Women  
 
Version: 1 Date: 30 May 2019  
 
Reviewer: Reviewer 2  
 
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?  
No - there are major issues  
 
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
No - there are major issues  
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
Yes - appropriate stati stical analyses have been used in the study  
 
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not 
overstated?  
No - there are major 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: This study addresses an interesting topic, namely the relationship 
between parity and low -grade albuminuria as a potential driver of an earlier observed increased 
risk of subsequent cardiovascular disease (CVD). The concept is of interest, although for 
decades, the debate has been whether higher parity actually causes CVD or whether confounders 
drive the associa tion. From that perspective, in my view, the authors could have formulated the 
background from the literature in their paper (intro and discussion) a bit more carefully. 
Methodologically, there are some serious concerns and limitations regarding the design  and 
execution of the study.  
 
 
REQUESTED REVISIONS:  
 
Design:  
- The authors excluded individuals with micro - or macroalbuminuria from the cohort. The 
rationale for this is unclear and was not provided. Albuminuria is very likely a continuum, with 
higher values reflecting a higher CV risk. Therefore, the authors shoul d also include the 
participants with albuminuria >30 mg/g in their analyses.  
 
- The cross -sectional design is a limitation of this study; it would have been much stronger if the 
authors had done a longitudinal analysis studying the association between pari ty and CV 
outcomes, adjusted for albuminuria.  
 
 
Execution:  
 
- Unfortunately, the analyses were not adjusted for parameters reflecting socio -economic status. 
This is essential, since even though a causal relationship between parity and outcomes is 
suggested, it is in my view more likely that other characteristics of the multiparous sub -
population are driving the association. The analyses were also not adjusted for prior history of 
CV disease; this could have also confounded the results.  
 
 
Interpretation:  
 
- The positive association between eGFR and albuminuria (Table 3) is remarkable, but not 
commented on by the authors. How can this be explained?  
 
- The data in Figure 1 are unadjusted, this should be replaced by a graphical representation of 
fully adjusted data (i.e. model 3 in Table 4), showing that only in women with 3 children or more 
the association is significant.  
 
Note: This reviewer report can be downloaded - see attached pdf file.  
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization th at 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
This reviewer has been rec ruited by a partner organization, Research Square. Reviewers with 
declared or apparent competing interests are not utilized for these reviews. This reviewer has 
agreed to publication of their comments online under a Creative Commons Attribution License 
attributed to Research Square and was paid a small honorarium for completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the w ebsite along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal