Residual Kidney Function and the Impact of Dialysis Modality

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

 “Residual Kidney Function and the Impact of Dialysis Modality”:

 

The manuscript is well-organized and provides a comprehensive review of residual kidney function (RKF) and its clinical importance in dialysis patients. It effectively integrates observational and clinical trial data, discusses measurement techniques, and highlights factors influencing RKF preservation. The topic is clinically relevant and timely, particularly for nephrologists and dialysis providers. However, the manuscript would benefit from improved clarity, refinement of certain sections for conciseness, and better integration of figures/tables with the text. There are also opportunities to strengthen critical analysis, update references, and avoid repetition

 

1. The manuscript largely summarizes existing knowledge rather than providing a novel perspective or critical synthesis. Consider adding a “Future Directions” subsection in the conclusion to highlight emerging techniques (e.g., 23Na-MRI, non-invasive RKF estimation) and research gaps, which would make the review more forward-looking.

 

2. While the manuscript is logically structured, some sections are very long (e.g., Sections 2 and 6). Breaking these into subheadings such as “Clinical Significance of RKF,” “Mortality and Cardiovascular Outcomes,” and “Modality-Specific Considerations” will make it better. RKF’s effect on mortality and cardiovascular risk is repeatedly mentioned in multiple sections (2, 3, and 6). Consider consolidating these discussions.

 

3. Much of the text reads as a descriptive compilation. A balanced critique of conflicting studies (e.g., differences in RKF decline between PD and HD, effects of incremental dialysis) would strengthen the review.

 

4. Some studies are cited without sufficient interpretation. For instance: BISTRO and balANZ trial results could be compared with potential reasons for variability in RKF decline rates, the clinical implications of “clinically negligible RKF” could be discussed in the context of current practice.

 

5. Tables 1 and 2 are informative but could be reformatted to improve readability: Include a column summarizing advantages and limitations of each marker/method.

 

6. Ensure all abbreviations (e.g., D, V) are clearly defined in the table legends.

 

7. Figures referenced (Figure 1 and Figure 2) are not included in the reviewed document. Ensure they are high-quality and align with the narrative.

 

8. The manuscript cites many key studies but lacks the most recent global guidelines or consensus on RKF preservation.

 

9. Consider citing KDIGO 2023 updates if applicable.

 

10. Some references are repeated (e.g., Chan CT et al., KDIGO conference paper appears twice: lines 404–405 and 549–550).
11. Verify that all statements, particularly those on percentages and GFR decline, are supported by references.

 

12. The text is generally clear professional language polishing will improve it: Example: “be er” → “better” (multiple occurrences due to formatting errors).

 

13. Avoid informal or ambiguous phrases such as “in an ideal world” (line 315–316); replace with “Ideally, …”

 

14. Maintain consistent tense, particularly when discussing past studies.

 

15. Ensure all abbreviations are defined at first use (e.g., UOP, UF, GDP, APD).

 

16. Standardize units: use “mL/min/1.73 m²” consistently.

 

17. Correct minor spacing and typographical issues (e.g., “li le” → “little”).

 

18. The conclusion could be strengthened by: Reiterating key clinical messages (e.g., routine RKF assessment, incremental dialysis considerations), highlighting gaps in knowledge and calling for standardized RKF measurement protocols.

 

19. Cite the article [Raghava, Alok, et al. "Optical Screening of Glycation Induced Structural Alterations in Serum Proteins of Diabetes Patients Using Spectroscopic Techniques." International Journal of New Technology and Research, vol. 2, no. 5, May. 2016] after lines 152-158 “…Multiple studies have shown reduced levels of inflammatory markers in dialysis patients with residual kidney function. In the CHOICE study, patients with urine output greater than 250 ml/day had lower levels of C-reactive protein and interleukin-6 compared to those with less urine output. (12) This has been corroborated in murine models, where higher levels of inflammatory markers including TNF α, IL-1 were seen in nephrectomized rats. (26)”. Add a sentence before citing Protein glycation and AGE-mediated structural alterations, as reported in diabetic patients, further contribute to kidney injury and inflammatory burden. (Raghav et al., 2016)”

 

 

Major Revision

 

Address repetition and improve flow by restructuring long sections, include critical appraisal of evidence and emerging strategies, revise tables and ensure figures are present and aligned with the text. perform careful language and formatting corrections.

 

If these issues are addressed, the manuscript will serve as a strong, practical review for clinicians and researchers in nephrology.

 

Author Response

Please see attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is a very well written review article which is easy to follow and comprehend. Only a few suggestions.1. Highlight the mortality impacts of insufficient HD compared with standard HD frequency, as this does seem to contradict your concept that residual renal function (RKF) must be preserved. 2. Worth also mentioning the cardiovascular mortality risks of PD versus HD, (Cheng Han Ng et al Int Urol Nephrol 2021) which again would appear to contradict your opinion that PD preserves RKF more effectively and hence could be inferred a survival benefit. 3. I have no doubt preserved RKF would improve quality of life and this would also be worth discussing with published evidence if available.  4. It is disappointing that there appears no effective way of improving RKF, other than by Tx. You could add the impacts of prolonged DGF post Tx which causes increased patient mortality at all time points. 

Author Response

Please see attached.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

“The authors have carefully revised the manuscript in line with all reviewer comments and editorial suggestions, and I am pleased to confirm that the manuscript is now ready for publication.”