PONE-D-20-33490

Liver transplant waitlist removal, transplantation rates and post-transplant survival in Hispanics

PLOS ONE

Dear Dr. Thuluvath,

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 believe that it is an interesting and well written article but it is needed to improve and to address such as the explanation regarding better graft and patient survival in Hispanic. Also please refer the comments in detail as followings.  

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Yun-Wen Zheng

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. 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

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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: Yes

Reviewer #2: Yes

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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: This retrospective cohort analysis confirmed that there are significant racial disparities in waitlist removal rates due to death/deterioration, transplantation rates and post liver transplant

mortality, especially in Hispanic. This paper is very well written and it seems that there is no problem in general.

I have some comments.

1. The waitlist removal group is consisted only due to death or deterioration + due to liver transplantation? Or is there any cause of waitlist removal cause?

2. In the discussion p.12, the authors mentioned that when they adjusted weight list removal for socioeconomic differences using surrogate markers such as education, insurance or employment status, the

differences in waitlist removal due to death/deterioration disappeared, but disparity in transplantation remained more or less unchanged. Why the disparity in transplantation remained more or less unchanged? What causes disparity in transplantation?

Reviewer #2: Thuluvath, et al. investigated risk analysis for waitlist removal of death/deterioration and transplantation by multivariate analysis, using UNOS data of more than 150,000. They found that Hispanics had higher waitlist removal due to death/deterioration and lower transplant rates than non-Hispanics. Also, Hispanics did have better graft and patient survival than non-Hispanics. When covariables including socioeconomic status was adjusted, the higher risk in removal of death/deterioration disappeared, but not for transplantation. They discussed that these results were observational and could not find good reasons. This is interesting manuscript, but lacks data and explanations to support their theory.

Major

1. The numbers of patients are not compatible. For example, the number patients who received transplant supposed to be 154818 x 0.569 =88,091. Looking at table 3, the number of the patients were 57864+7221+10725+3573+985=80,368. Ten percent of the patient`s data are missing. These incompatibilities can lose quality of statistics of this study.

2. The authors should have better explanation regarding better graft and patient survival in Hispanics, not just to conclude with “biological reasons”. What are the biological reasons? Since Hispanics had higher MELD score with higher dialysis rates, lower KPS, etc, this population should have worse graft and patient survival. We can’t agree with the explanation for “it is plausible that ……“, since Hispanics had higher risks than other races.

3. Showing Figure 3 A and 3B without matching SEC does not make sense. It is important to show the graft and patient survival curves after matching with covariables including SEC. We think “Sensitivity analysis” paragraph and “Impact of socioeconomic status….” paragraphs should be combined to one. Also, it is meaningless to show duplicates in Table 2 and Table 5. They should only show Table 5, with reorganized paragraphs in the Result section.

4. The authors need to discuss why malignancy is the major cause of death for Hispanics.

Minor

1. We could not find the data that explains “more Asians received poor-quality graft (defined as DRI>2) than whites ……..” in Table 1.

2. Introduction and Result section, multivariate analyses for not “patient survival” and “graft survival”, we think “patient mortality” and “graft failure”.

3. What does 93.2% mean at introduction section (line 8)? The author should have more care for adding this number, or exclude this from the manuscript.

4. Page 9, in multivariate analyses for graft and patient, “gender” should be included as a risk factor.

5. Page 12, line 18, “weight list”=>”waitlist”

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Reviewer #1: Yes: Soichiro Murata

Reviewer #2: No

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Liver transplant waitlist removal, transplantation rates and post-transplant survival in Hispanics

PONE-D-20-33490R1

Dear Dr. Thuluvath,

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.

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Kind regards,

Yun-Wen Zheng

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 #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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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: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: 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 #1: Yes

Reviewer #2: Yes

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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: 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: Everything requested by the reviewer has been corrected and there is no problem. I think this manuscript is acceptable.

Reviewer #2: The paper “Liver transplant waitlist removal, trnasplantation rates and post-transplant survival in Hispanics”. is now correctly revised. The authors have answered all our comments wisely. We could not find any issues now.

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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