Chronic Antibody-Mediated Liver Rejection: More than Meets the Eye
, Ignacio Iturrieta-Zuazo 1, Rubén Ballester-González 1, Nieves Alonso-Alarcón 1, Esther Moreno-Moreno 2, José Luis Castañer-Alabau 1 and Israel Nieto-Gañán 1Round 1
Reviewer 1 Report
This case is certainly an instructive case of AMR in the distant period after liver transplantation. However, there seems to be a leap in logic between the case presentation and author’s assertion. Their conclusion of the article is not satisfied only by clinical course of this single case. Rather, the author should describe more detail about the specific clinical feature of this case to illustrate what is different from other cases of AMR to possess value in the trust sense of the “case report”.
Major concerns
- This article is basically nothing more than a case report. However, the conclusion of this article seemed to be too generalized. It is unreasonable to develop argument that described in the discussion session with only one case of AMR. The evidence derived from clinical course is not enough to support the discussion.
Minor problems
- The figure 3 contains concrete date and these should be converted into elapsed days since patient’s administration. These information are personally identifiable data.
- The Figure 1 and Figure 2 describe almost same things. The one or the other is unnecessary to present the clinical course of the case. In addition, the timing of Rituximab infusion described in Figure 1 is not consistent with Figure 2.
Author Response
The discussion section offers a brief literature review on the role of anti-HLA antibodies in liver rejection. The conclusions have been modified following the reviewer's indications.
As the reviewer suggests, in Figure 3 the dates have been changed by the number of days post- transplantation.
As suggested by the reviewer, we have omitted Figure 1 and lkeep Figure 2 for being more informative. In addition, we have checked the rituximab and plasmapheresis cycles to include them correctly in this figure.
Reviewer 2 Report
This paper is an interesting clinical case of chronic antibody-mediated liver rejection in a patient undergoing liver transplantation. However, a weakness of the clinical case is that there is no previous blood sample in order to confirm that there was no preformed DSA against the donor HLA, from the first transplant.
Author Response
As the reviewer points out, it would have been very useful to have a pre-transplant serum, which was not possible. For this reason, one of the aspects in which we wanted to emphasize in this article is the need for standardized protocols for collecting samples in the context of liver transplantation. In this way, the diagnosis of humoral rejections as well as the immunological monitoring of these patients would be facilitated.
Reviewer 3 Report
This case report is well-written and well-argued. I only suggest two questions in order to improve this article.
1. There are several recent publications that could have been named:
- 2. The other question: Why C1q fixing antibody assay by luminex was not performed in this case?. It could have been interesting.
Author Response
We thank the reviewer for the suggested bibliography, which we have included in the article.
As the reviewer indicates, the C1q assay for the detection of complement-fixing antibodies would add value to the study of this case. Unfortunately, this reagent is not approved by the Management of our Hospital at the moment, so we cannot carry out this type of assays.
