The Usefulness of Extended Inflammation Parameters and Systemic Inflammatory Response Markers in the Diagnostics of Autoimmune Hepatitis

Round 1

Reviewer 1 Report

The authors have shown the usefulness of EIP in the diagnosis of autoimmune hepatitis in a limited sample, and this study is interesting. However, some points require to be addressed by the authors:

Minor revision

1, Do each parameter correlate with the severity of cirrhosis in Figures 3 and 4?

If possible, the authors should blot each parameter with the histopathological severity of cirrhosis and investigate the correlation.

2, Do each parameter correlate with prognosis and efficacy of therapeutic agents?

Author Response

1, Do each parameter correlate with the severity of cirrhosis in Figures 3 and 4?

In the Figure 3 we presented values of examined markers which differed significantly between AIH patients with and without already developed liver cirrhosis (AAR, FIB-4, NEUT-GI, PLR, RPR and MPR). We did not correlate them with the severity of liver cirrhosis, because it was not the aim of our study; we did nor perform liver biopsy in investigated patients. It could constitute a further direction of our survey. On the other hand, Figure 4 shows ROC curves with a proposed diagnostic accuracy of the above-mentioned parameters in the diagnostics of liver cirrhosis. Here we did not aim to correlate the results with severity of liver fibrosis, either.

If possible, the authors should blot each parameter with the histopathological severity of cirrhosis and investigate the correlation.

This issue will concern the aim of our next study. Except for the assessment of the tissue concentration of inflammatory markers in the liver samples of examined patients, we will compare these results with serological concentration of assessed parameters, as well. The current survey constitutes a pilot one; we wanted to find out whether the proposed markers could be potentially perceived as indices significant in the course of AIH.

2, Do each parameter correlate with prognosis and efficacy of therapeutic agents?

It was not the aim of our current investigation. Nevertheless, it is undoubtedly another crucial aspect that requires further investigation in following studies. What is more, the data on this topic seem to be absent in available literature. Therefore, it is an additional reason indicating an essential role of studying the topic mentioned in the discussed question. 

Reviewer 2 Report

This study compares the EIP values between 30 AIH patients and 30 healthy controls in order "to assess the usefulness of the EIP and systemic inflammatory response markers in the diagnostics of AIH". AIH patients showed significantly higher EIP values. The Authors conclude that "EIP and systemic inflammatory response markers may prove useful in detecting AIH, as well as in facilitating and accelerating differential diagnosis".

 

The design of the study (comparison of EIP between AIH and healthy controls) allows to conclude that in AIH patients EIP and systemic inflammatory response markers are significantly altered in comparison to healthy volunteers, but no comparison is performed with other liver diseases of different aetiologies, therefore the conclusion that these markers "may prove useful in detecting AIH, as well as in facilitating and accelerating differential diagnosis" is not substantiated by the data provided. In other terms, one or more pathological control groups are needed to assess the diagnostic usefulness of EIP and systemic inflammatory response markers in AIH.

Author Response

Indeed, our survey was limited to the assessment of the group of AIH patients, therefore writing about the usefulness of examined markers in the differential diagnosis of liver disorders could be definitely misleading and was already corrected. The current study was a pilot one and it is the reason for choosing the population of patients with a single pathology - AIH. In the future we will try to compare diagnostic accuracy of assessed inflammatory markers between patients with different liver pathologies (including e. g. alcoholic liver disease and metabolic-associated liver disease). Therefore, this above-mentioned expression from the last sentence of Conclusion was modified (written in the manuscript in red colour): Summing up, the analysed parameters may turn out to be useful in detecting AIH and in looking for features of already developed liver cirrhosis in its course. Nevertheless, at this stage it is hard to speculate and clarify whether observed deviations in examined inflammatory parameters are related only to AIH or maybe to to the general idea of liver disorders. Therefore, following studies should concern the evaluation of EIP in various liver disorders to compare the obtained results and to elucidate their potential status in liver diagnostics.

Reviewer 3 Report

Domerecka, et al. shows EIP and systemic inflammatory response markers are useful in the diagnosis of AIH.  This is a novel and significant, and useful for future practice.  This manuscript needs some improvement.

1.  Most of AIH cases in this study received immunosuppressive therapies such as steroids. Could their treatments alter the markers?  Please mention in discussion.

2.  As described in discussion,  viral infections or other inflammatory disease could alter the composition of the markers.  Although this study is a comparison of AIH and healthy subjects, do you think these markers could be markers that distinguish AIH from other chronic hepatitis such as viral hepatitis?  Please describe in discussion.  

3.  Please spell out "RPR, MPR, NLR, PLR, RLR" in Abstract.

4. RPR (0.91) → RPR (AUC = 0.91) ? (Line 45)

 I hope these comments will be helpful.

Author Response

1. Most of AIH cases in this study received immunosuppressive therapies such as steroids. Could their treatments alter the markers? Please mention in discussion.

It is an essential point to be raised. We included the additional part to the Discussion (written in the manuscript in red colour and and supplementary table number 6 with the results.): AIH patients investigated in the study were in the phase of clinical and laboratory remission. We did not perform liver biopsy in them. To verify a potential impact of steroids and immunosuppressants intake on the results in assessed inflammatory markers, we compared the all AIH subgroups with each other (steroids vs immunosuppressants vs steroids + immunosuppressants). Of note, we found significant differences according to NEUT-RI and AAR. Values of these parameters were significantly lower in AIH patients treated pharmacologically. It is quite an interesting observation because of the chronic and maintenance character of immunosuppressive therapies in patients included in research group. These were long-lasting therapies existing through the years (with the median of the disease duration of 13 years), therefore it is hard to suspect with certainty the presence of potential relationship between the treatment and the character of the results in examined patients. Nevertheless, this issue requires further exploration, data obtained from liver biopsy and the investigation of AIH patients with active type of the disease, as well. According to the available literature, we seem to present such data for the first time. Probably, chronic immunosuppressive therapy was a factor which caused a decrease of hepatitis’ severity and it was reflected by lower values of NEUT-RI and AAR. Thu, it appears that NEUT-RI could be explored as a potential valuable marker differentiating AIH patients with and without active inflammation.  

2. As described in discussion, viral infections or other inflammatory disease could alter the composition of the markers.  Although this study is a comparison of AIH and healthy subjects, do you think these markers could be markers that distinguish AIH from other chronic hepatitis such as viral hepatitis?  Please describe in discussion. 

We included the additional part to the Discussion: Our study concerned only the population of patients with a single liver disease; AIH patients turned out to present deviations in evaluated inflammatory markers. According to the data obtained in the current survey, it would be interesting to confront them with corresponding results acquired from people with viral hepatitis or alcoholic hepatitis to clarify whether abnormalities in inflammatory markers are typical for the general idea of inflammation within the liver or maybe for selected liver pathologies. We believe that it is still the early beginning of the exploration of EIP in liver diagnostics and further surveys will improve our knowledge concerning this issue together with its practical use among patients.    

3. Please spell out "RPR, MPR, NLR, PLR, RLR" in Abstract.

The above-mentioned terms were spelled out.

4. RPR (0.91) → RPR (AUC = 0.91) ? (Line 45)

The expression used in the Abstract was corrected (AUC = 0.91).

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.