Iron deposition in autopsied liver specimens from older patients receiving intravenous iron infusion

Hiroyasu Akatsu; Toshie Manabe; Yoshihiro Kawade; Hajime Tanaka; Takayoshi Kanematsu; Kazuyuki Arakawa; Yoshiyuki Masaki; Chie Hishida; Takeshi Kanesaka; Norihiro Ogawa; Yoshio Hashizume; Koichi Tsuneyama; Hirotaka Ohara; Mitsuo Maruyama; Takayuki Yamamoto

doi:10.1371/journal.pone.0237104

Peer Review History

Original SubmissionFebruary 26, 2020
1 Apr 2020 Decision Letter - Tatsuo Kanda, Editor PONE-D-20-05549 Iron deposition in autopsied liver specimens from older patients receiving intravenous iron infusion in terminal PLOS ONE Dear Prof. Hiroyasu Akatsu, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by May 16 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. 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As mentioned in your Limitations section, causation cannot be determined by retrospective studies; thus, please revise any causality statement made in the Abstract and Discussion sections. 3. Please confirm if the title is correct, should it be " Iron deposition in autopsied liver specimens from older patients receiving intravenous iron infusion" 4. Thank you for stating the following financial disclosure: "The authors received no specific funding for this work." At this time, please address the following queries: Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution. State what role the funders took in the study. 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Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: In the present study, authors investigated iron deposition in autopsied live specimens from patients receiving intravenous iron infusion. They concluded that iron administration by long-term total parenteral nutrition (TPN) affected the iron deposition in liver. Although this is a well-written paper that presents interesting data, there are several drawbacks in the manuscript Major points 1) To the best of my knowledge, this is the first study to demonstrate the association between iron administration and iron deposition in liver specimens. I think the authors should place more emphasis on the point in both the background and discussion section. 2) Regrettably, the authors simply indicated conditions of iron administration in terms of with or without iron staining (Table 3), I think it would be useful if the authors gave more data according to the iron staining grade. 3) The authors state that clinical data on iron administration including volume, data, periods and frequency were assessed in the method section. Analysis of the frequency of iron administration should be added to the result section. 4) Page 7 Line 103: ‘At least (three independent investigators)’ is unclear. Can the number of investigators differ according to each cases? Moreover, was there an intraobserver error? These points should be explained. 5) Bowel resection could be related to the iron overload. In the table 1, iron-positive patients were more likely to have a history of surgery. The authors should explain in more detail the data and further discussion needs to be included to address the point. 6) What is the best predictable marker for iron deposition in terms of the iron staining in autopsied liver specimens? I think the quality of this paper could be enhanced by adding the data. 7) There are quite some odd wording and use of grammar. English of the manuscript has to be checked by a native speaker. Minor points 1) In the abstract section, the authors should definitely describe the purpose of the study. 2) In the abstract section, storage condition of the sample was unnecessary. 3) Page11, Line167; ’81.2%’ should be changed into ’82.1%’. Reviewer #2: 1. Line 275, “3.54 μmol/year or 10 μmol (1 mg)/day” Why iron amount per year is lower than that per day? 2. Line 246, “Fe 17.5 μmol (1 mg)/day” Line 275, “10 μmol (1 mg)/day” Line 296, “10 mmol (1 mg)/day.” Which is correct? 3. Table 3, “Iron given 1 year before death (μmol L).” “Total iron volume during inpatient infusion (μmol L) “ Please explain the unit “μmol L”. I think total iron amount administerd can be described as mass rather than concentration. 4. In table 4 and 5, why did total cohort including patients without iron staining in the liver show high ferritin level? 5. Multivariate analysis can be performed using factors in Table 3 and 4. 6. Please add the factors of TPN and iron infusion in Table 5. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0237104.r001
Revision 1
25 May 2020 Author Response Point-by-point response to reviewers’ comments Thank you very much for your time and valuable feedback. We have carefully considered your comments and suggestions and have revised our manuscript accordingly. We have included our responses to the reviewers’ comments below. For clarity, the reviewer’s comments are shown in blue and our responses are shown in black. Reviewer reports: Reviewer #1: In the present study, authors investigated iron deposition in autopsied live specimens from patients receiving intravenous iron infusion. They concluded that iron administration by long-term total parenteral nutrition (TPN) affected the iron deposition in liver. Although this is a well-written paper that presents interesting data, there are several drawbacks in the manuscript Major points 1) To the best of my knowledge, this is the first study to demonstrate the association between iron administration and iron deposition in liver specimens. I think the authors should place more emphasis on the point in both the background and discussion section. Thank you very much for your kind comment and pointing out the significance of our work. Yes, we also believe that this is the first study demonstrating the association between iron administration and iron deposition in the liver, and we have added statements to the Introduction and Discussion sections emphasising this point. P. 5; Lines 61-62. However, the association between iron administration by TPN and iron deposition in the liver has never been examined. P. 15; Lines 241-242. This is the first study to demonstrate an association between iron administration and iron deposition in post-mortem liver specimens. 2) Regrettably, the authors simply indicated conditions of iron administration in terms of with or without iron staining (Table 3), I think it would be useful if the authors gave more data according to the iron staining grade. Thank you very much for this important suggestion. As you mentioned in comment #4, however, the grading of iron staining was variable, even among our expert observers. For this reason, we used positive or negative iron staining as the principal comparison in Tables 1–4. However, in Table 5, we have presented our laboratory findings in post-mortem serum according to the grade of iron staining. We hope this is sufficient. 3) The authors state that clinical data on iron administration including volume, data, periods and frequency were assessed in the method section. Analysis of the frequency of iron administration should be added to the result section. As suggested, we have added the method of data collection for iron administration to the methods section and have modified our explanation of the data in the Results section. P. 5; Lines 75-77. Data on the number of days and the volume of iron administration were collected for one year prior to the patients’ death and during the entire period of hospitalization. P. 12; Lines 188-192. The number of days of TPN administration was significantly higher in the iron-positive group compared with the iron-negative group both in the year before death (p = 0.004) and during hospitalization (p = 0.038). However, the volume of TPN was not significantly different between the groups in the year before death (p = 0.222) or during the hospitalization (p = 0.220). 4) Page 7 Line 103: ‘At least (three independent investigators)’ is unclear. Can the number of investigators differ according to each cases? Moreover, was there an intraobserver error? These points should be explained. The “three independent investigators” are co-authors of the manuscript. We have identified the investigators using their initials and have added an explanation of how we minimised interobserver error. P. 7; Line 104-108. Three investigators (H.A., K.T., H.O.), who specialize in the study of liver or liver pathology, evaluated the Prussian blue staining in each liver sample independently and recorded their findings on a custom data collection form. We verified the accuracy of these evaluations by comparing the forms of each investigator and resolving any discrepancies through discussion. 5) Bowel resection could be related to the iron overload. In the table 1, iron-positive patients were more likely to have a history of surgery. The authors should explain in more detail the data and further discussion needs to be included to address the point. P. 9; Lines 144-149. The most frequent cases of surgery were for femoral fracture (10 cases), female reproductive ailments (7 cases) or digestive system disorders outside of the intestine (7 cases). There were two cases of bowel resection for colorectal cancer, and both patients had an iron deposition grade of I or II in the liver. Patients with a history of fractures, other than a femoral fracture, were more likely to be iron-negative. 6) What is the best predictable marker for iron deposition in terms of the iron staining in autopsied liver specimens? I think the quality of this paper could be enhanced by adding the data. In the Results section, we have added an analysis of predictable markers for iron deposition using logistic regression models. These results are presented in Table 6 with the subheading, “Factors associated with iron staining.” P. 12; Lines 218-224. Logistic regression analysis revealed that male sex (odds ratio [OR], 4.119; 95% confidence interval [CI], 1.773-9.566) and iron in post-mortem serum (OR, 1.025; 95% CI, 1.010-1.041) were factors associated with iron staining if the volume of TPN was included in the adjusted variables. If the volume of TPN was excluded from this analysis, UIBC in post-mortem serum (OR, 1.014; 95% CI, 1.003-1.022) and administration of TPN (OR, 3.586; 95% CI, 1.664-7.732) were factors significantly associated with iron staining. 7) There are quite some odd wording and use of grammar. English of the manuscript has to be checked by a native speaker. Our manuscript was revised by professional scientific editors who are native English speakers. Minor points 1) In the abstract section, the authors should definitely describe the purpose of the study. We have added the purpose of the study to the abstract. P. 2; Lines 6-8. The aim of the study was to assess the influence of iron administration by long-term TPN on iron deposition in post-mortem liver samples isolated from older deceased patients. 2) In the abstract section, storage condition of the sample was unnecessary. We have revised this sentence. P. 2; Lines 15-17. Samples were collected for the measurement of unsaturated serum iron, serum iron, albumin, prealbumin, hepcidin, and IL-6 concentrations. 3) Page11, Line167; ’81.2%’ should be changed into ’82.1%’. We have corrected 81.2% to 82.1%. P. 11; Line 184. ……in the iron-positive group (82.1%; p<0.001) Reviewer #2: 1. Line 275, “3.54 μmol/year or 10 μmol (1 mg)/day” Why iron amount per year is lower than that per day? Thank you for pointing this out. It was a mistake, and we have corrected it in the text. P. 19; Lines 316-317. The maximum amount of iron administered, 3,535 μmol/year, was nearly equivalent to 10 μmol (0.57 mg)/day 2. Line 246, “Fe 17.5 μmol (1 mg)/day” Line 275, “10 μmol (1 mg)/day” Line 296, “10 mmol (1 mg)/day.” Which is correct? “Fe 17.5 μmol (1 mg)/day” is correct. The others have been changed. 3. Table 3, “Iron given 1 year before death (μmol L).” “Total iron volume during inpatient infusion (μmol L) “ Please explain the unit “μmol L”. I think total iron amount administerd can be described as mass rather than concentration. Thank you for your comment. This was also an error. The “L” has been deleted. 4. In table 4 and 5, why did total cohort including patients without iron staining in the liver show high ferritin level? In patients with chronic inflammatory disease, the higher ferritin levels are likely to be caused by problems in iron metabolism rather than a reflection of iron deposition from TPN. In the present study, all patients were hospitalised and at the end stages of their lives. We believe that the ferritin levels in these particular patients are not related to iron deposition in the liver. We have therefore included an explanation for this in the Discussion section and have added reference 27. P. 20; Lines 325-331. However, the ferritin level was higher in some patients without iron staining than those with iron staining. In patients with chronic inflammatory diseases, higher ferritin levels are more likely to be caused by problems in iron metabolism whether there is a lot of iron or not, that is, regardless of the accumulation of iron [27]. In the present study, all patients had been hospitalized with terminal diseases, and their median age was 85 years. Among some of these patients, the ferritin level may not be related to iron deposition in the liver. 5. Multivariate analysis can be performed using factors in Table 3 and 4. 6. Please add the factors of TPN and iron infusion in Table 5. Based on your suggestions in comments #5 and #6, we have analysed factors associated with iron staining using logistic regression models. These results are presented in Table 6 of the Results section with the subheading “Factors associated with iron staining.” P. 14; Lines 218-224. Logistic regression analysis revealed that male sex (odds ratio [OR], 4.119; 95% confidence interval [CI], 1.773-9.566) and iron in post-mortem serum (OR, 1.025; 95% CI, 1.010-1.041) were factors associated with iron staining if the volume of TPN was included in the adjusted variables. If the volume of TPN was excluded from this analysis, UIBC in post-mortem serum (OR, 1.014; 95% CI, 1.003-1.022) and administration of TPN (OR, 3.586; 95% CI, 1.664-7.732) were factors significantly associated with iron staining. https://doi.org/10.1371/journal.pone.0237104.r002
8 Jun 2020 Decision Letter - Tatsuo Kanda, Editor PONE-D-20-05549R1 Iron deposition in autopsied liver specimens from older patients receiving intravenous iron infusion PLOS ONE Dear Dr. Hiroyasu Akatsu, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== ACADEMIC EDITOR: Please give some comments to iron drugs (Reviewer 3) ============================== Please submit your revised manuscript by Jul 23 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Tatsuo Kanda, M.D., Ph.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: (No Response) Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: (No Response) Reviewer #3: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: (No Response) Reviewer #3: I Don't Know ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: (No Response) Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: (No Response) Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for revising the problem. The manuscript has been much improved according to the review comments. Furthermore, the second version had been enhanced by adding an analysis of predictable markers for iron deposition using multivariate analysis. Reviewer #2: (No Response) Reviewer #3: It is a very interesting paper that warns of iron overdose due to the iron content in high calorie infusion formulations. It is unknown how many people were receiving iron drugs for anemia. Give some comments about iron drugs in discussion section. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No Reviewer #3: Yes: Hidehiro Kamezaki [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0237104.r003
Revision 2
15 Jul 2020 Author Response Point-by-point response to reviewers’ comments Thank you very much for your time and valuable feedback. We have carefully considered your comments and suggestions and have revised our manuscript accordingly. We have included our responses to the reviewers’ comments below. For clarity, the reviewer’s comments are shown in blue and our responses are shown in black. Reviewer reports: Reviewer #1: Thank you for revising the problem. The manuscript has been much improved according to the review comments. Furthermore, the second version had been enhanced by adding an analysis of predictable markers for iron deposition using multivariate analysis. Thank you very much. Reviewer #3: It is a very interesting paper that warns of iron overdose due to the iron content in high calorie infusion formulations. It is unknown how many people were receiving iron drugs for anemia. Give some comments about iron drugs in discussion section. Thank you very much for your comments. According to the medical record, none of the patients were receiving iron drug for the anemia. Basically, the hemoglobin level of the elderly is often lower than the normal value, but this is because of iron utilization disorder in the terminal elderly. The attending physician did not adjust the iron preparation due to some fluctuation in hemoglobin. In addition, they had not checked strictly the serum iron, unsaturated iron binding capacity, and ferritin level. The iron agent contained in daily TPN is the purpose of daily iron supplementation rather than the purpose of improvement. In addition, there were no cases where iron was administered to improve the anemia. We added and described these points. P. 18; Lines 290-294. In this study, haemoglobin level of many cases was a little below the normal level. But none of the cases had intensive intravenous iron administration for therapeutic purposes under the diagnosis of iron deficiency anemia. In almost all cases, an all-in-one bag TPN formulation containing a mineral component (iron dose of 1.1 mg/bag) was used for daily iron supplementation. After checked in-house 1. Please ensure that you refer to Table 6 in your text as, if accepted, production will need this reference to link the reader to the Table. P. 14; Lines 221, and 224 Thank you very much for the advice. I have referred to Table 6 in text at P.14; Lines 221, and 224. https://doi.org/10.1371/journal.pone.0237104.r004
21 Jul 2020 Decision Letter - Tatsuo Kanda, Editor Iron deposition in autopsied liver specimens from older patients receiving intravenous iron infusion PONE-D-20-05549R2 Dear Dr. Hiroyasu Akatsu, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Tatsuo Kanda, M.D., Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #2: (No Response) Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: (No Response) Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: (No Response) Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #2: (No Response) Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #2: (No Response) Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #2: (No Response) Reviewer #3: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #2: No Reviewer #3: Yes:** Hidehiro Kamezaki https://doi.org/10.1371/journal.pone.0237104.r005
Formally Accepted
23 Jul 2020 Acceptance Letter - Tatsuo Kanda, Editor PONE-D-20-05549R2 Iron deposition in autopsied liver specimens from older patients receiving intravenous iron infusion Dear Dr. Akatsu: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Tatsuo Kanda Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0237104.r006

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