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The authors needs to work on improving quality of English comprehension.
Please consider the following edits:
Abstract
Every year, 5 to 10% of patients with liver cirrhosis and with accumulation of fluid in the peritoneal cavity become develop RA while undergoing standard treatment (low sodium diet and diuretic doses up to 400 mg/day of spironolactone and 160 mg/day of furosemide).
The consequent activation of renin- angiotensin and sympathetic systems and increased renal sodium re-absorption occurs during the course of the disease.
Cirrhotic patients with refractory ascites RA have poor prognoses and are at risk for developing serious complications.
Introduction
Line 56: disease course
Definition of RA
Line 91: 5.2 g of salt/day.
Line 95: What does this mean?
Line 107: Refractor ascites frequently ….
Line 110: …….patient referral to a liver transplant center is recommended the rule.
The pathogenesis of ascites in liver cirrhosis
114. …. to explain the reason for forming ascites in end stage liver disease…
154. So-called False-refractory ascites
182. …non-compliant patient who does not strictly follow a low-sodium diet (≤ 90 mmol/d).
189. Such an approach is ….
206. ……or hepatocellular carcinoma, respectively. In these scenarios the lack of response to diuretic therapy occurs due to the disease features.
Please use the word “paracentesis” instead of ‘fluid evacuation’ while referring to removal of ascetic fluid.
280. Change to- The most common adverse effects after removal of more than 5 liters of ascetic fluid include weakness, dizziness and syncope.
Line 288-289. Please rephrase with correct English comprehension
TIPS- Please describe briefly what is the stent made up of?
388- Rephrase this paragraph.
Portal hypertension (PH) develops when there is a pressure gradient of >10 mm of Hg, between the portal vein and the inferior vena cava (IVC) called portal pressure gradient (PPG).
364. What about nutritional status of patients? Improves or worsens?
368. Use numbering like: 1) technical complications:
372. …after TIPS creation….
386. Are the authors sure these patients with EF <60% are excluded? Because normal EF can be 55%
Please remove the slash ( “/ ” ) sign from unnecessary locations like line 441, 442, 469, 470, 606, etc
Line 446: Why is it not necessary to give albumin? Please give a short reason which entails that slow removal of fluid does not cause a significant change in osmolarity or sodium shifts, release of vasoactive amines, etc
Please avoid using the phrase “as a rule…” because nothing is definitive in medical sciences in general. You can say “ it is recommended….”
498- correct font size for “ vasoconstrictive agents”. Please make sure fonts in the paper are uniform, it appears some are just one size off.
501: It is a V2….
509. ….it was found that vaptans….
605. Indwelling catheter placement is associated with risk of complications and perhaps increased mortality. It may be used as a palliative measure.
629. Start the sentence with “Refractory ascites is a …..”
Table 1:
Side effects of diuretics are more than just dyselectrolytemia, please name atleast 4-5 most common ones and also specify what type of dyselectrolytemias?
Line 37, Consider changing to: Every year, 5 to 10% of 37 patients with liver cirrhosis with ascites become refractory to standard treatment (low sodium diet and diuretic doses up 39 to 400 mg/day of spironolactone and 160 mg/day of furosemide).
Line 41, Change to: The consequent activation of renin- angiotensin and sympathetic systems causes increased renal sodium re- absorption which further worsens ascites.
Line 52: change to “ascitic” fluid
Line 63: change to “…the average survival period of patients decreases to…..”
Line 73: delete (RA)
Line 80: change to “…when a patient does not respond….”
Line 152: Please rephrase the header statement
Line 154: replace the word ‘diagnosed’ with ‘labelled’
Line 155: rephrase “Therefore, the correctness of therapy, in each patient individually, should be assessed first.”
Line 156, Change to: Loop diuretics (which worsen hyperaldosteronism) as monotherapy or insufficient doses of aldosterone antagonists (relative to the degree of RAA axis activation) are not the recommended therapies.
Line 160, change to: Similarly, unnecessary high doses of diuretics induce excessive diuresis leading to a negative fluid balance, inadequate weight reduction and pre-renal kidney injury.
Line 183 onwards: Under the section of “approach to patient with RA” I recommend the authors state the initial ascetic fluid analysis in terms of SAAG and total protein numbers. The role of portal HTN driving ascites causing a SAAG of >1.1 vs other causes exudative ascites. Also the role of total protein level in ascetic fluid that helps differentiates right heart failure and cirrhosis related ascites.
Line 213: What is a paracentesis hematoma? Please describe this for the readers
Line 215, please rephrase: you can mention there is no significant benefit of transfusing ____ to prevent bleeding from para…
Line 248: This condition may not be asymptomatic, sometimes patients complain of weakness, dizziness and syncope
Line 254, change to: “Twenty percent intravenous albumin…..”
Line 291: “Contraindications for paracentesis:”
Line 297: Please mention the section of diuretics in earlier part of the paper since this section should talk about therapies for RA which were listed as Number 1 to Number 5 (Line 200).
Line 311: Please do not use short-hand when you start a paragraph or a new section (please write the full form of TIPS here i.e, Transjugular intra-……..)
Line 313: Please clearly describe the procedure. Please state “A stent is placed across the hepatic vein and the portal vein….” And “The stent may be dilated with a balloon subsequently……”.
What is the normal portal pressure, how is it measured? What is the HVPG and how do we measure (remember this is different from direct portal vein pressure)?
Line 332: please remove the parenthesis
Line 334: Delete “(an increase in dry body weight and total nitrogen level)”
What about contraindication for TIPS placement for porto-pulmonary HTN. Also what are the right sided pressures above which we do not recommend TIPS placement?
Is it safe to use it in HPS?
Line 453: describe what vaptans or V2 receptor antagonists in a more organized fashion
Line 456: remove the bold font
Line 485: please remove the word ‘standard’
Line 567: please delete this: “The detailed description of the 568 aforementioned procedures can be found in recently published reviews authored by Lv 569 et al. (2018), Garbuzenko et al. (2017), and Al-Zoubi et al. (2016). “
Placement of pleural catheter is not recommended in hydrothorax and increases risk of mortality. Please give some data to support for or against this statement.
Line 573: remove false resistance and replace with ‘inadequately treated RA’.
Line 578: “…….widespread clinical use can be issued.”
The writing has improved, please consider above changes.
The paper seem to encompass the necessary aspects of management of refractory ascites. I would like to see a paragraph on right sided pleural effusion associated with some cases of refractory ascites.
There are several grammatical errors which need to be corrected. I suggest the authors have the paper reviewed by a native English speaker
I also suggest you create a table which lists the treatments available for refractory ascites.
In the methods it is mentioned that medline search was performed. Of the 377 papers how many were review articles, meta-analysis, clinical trials. This is for the information of the editors and may or may not be included in the final manuscript.
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Few grammatical mistakes noted, and a few spelling mistakes
References were provided appropriately
The review of management and pathogenesis is basic and is unchanged, no new ideas or changes were noted or highlighted
Several chapters in GI manuals explain the exact details except for some epidemiological data
The introduction is adequate
Medline search was performed on published articles from 2005-2018
It is unclear which data was extrapolated from the search of published papers and how it was analyzed
A series of management plans and basic physiology was discussed, no novel ideas noted
The review is written in coherent manner.
The article was well written however at no point did this reviewer note any information which was novel or new to management of this condition.
I believe the authors did a good job in detailing the pathophysiology of this medical condition, however the information currently available is similar to the written paper. No novel ideas were reviewed or suggested based on the Medline search. I would suggest a meta-analysis instead to re confirm the management plans
The article draws extensively from the collected pool of literature. The material is well researched and largely correct.
A review of refractory ascites and its management is a good topic for review. The material presented in the article is relevent and would be a good resource for physicians who are not specialized in the filed of hepatology.
The introduction is appropriately concise and well structured.
The article suffers from serious errors in grammatical and sentence structuring throughout. The authors have failed to present their findings in clear and unambiguous English. The information they have presented requires significant restructuring and grammatical revision. Virtually every paragraph suffers from errors in grammar, punctuation, or sentence structure. I would recommend the authors have the manuscript reviewed by a native English speaker for revision.
The survey methodology is comprehenisve and unbiased.
The research of the available material is clearly rigorous and thorough.
The methodology is clearly described.
The review is logically organized. The paragraphs and subsections are incoherent. Specifically, the section "Unusual clinical situations" Lines 150-180 is poorly organized and unclear. It also suffers from errors in grammar and sentence structuring.
The subsections under "Treatment of Refractory ascites" need to be more succinct and relevant to the topic. The sections should focus on the efficacy of each modality relative to resolution of ascites, improvement in renal perfusion, and reduction in mortality (if any). They should also include the rates of complication and any advantages and disadvantages of one modality relative to the others (if applicable). Going into detail, for example, on the Z technique during paracentesis and the effect of hydroxylated starch on hepatic lysosomes, is irrelevant to the topic of refractory ascites and does not require elaboration.
No comment
The first section from Line 33 to line 150 is relatively well organized with relatively minor errors in English. The section from lines 151 to 480 needs to be extensively re-worked for English and well as organization. It seems that these two sections were written by different people. Regardless, the entire article needs to be reviewed by someone with better understanding of punctuation, grammar, and sentence structure.
The section under Treatment Modalities is too long and rambling. The information presented needs to be more concise and useful to the reader in terms of risk vs benefit.
The material that the authors have presented is no doubt well researched and extremely relevant to the the physician managing refractory ascites. It needs extensive revision for grammar and sentence structuring. Much of the wordage is redundant and the article becomes unfocused and wanders into unrelated topics in the Treament modalities section. I cannot recommend its publication in its current form.
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