Neutrophil gelatinase-associated lipocalin partly reflects the dynamic changes of renal function among chronic hepatitis C patients receiving direct-acting antivirals

Yen-Chun Chen; Chen-Hao Li; Ping-Hung Ko; Chi-Che Lee; Ru-Jiang Syu; Chih-Wei Tseng; Kuo-Chih Tseng

doi:10.1371/journal.pone.0256505

Peer Review History

Original SubmissionMay 10, 2021
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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes 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: Authors proposed neutrophil gelatinase-associated lipocalin partly reflects the dynamic changes of renal function among CHC patients receiving DAA. It would give another point of view for clinical daily practice. I have several questions as below. 1. In table 1, authors showed baseline characteristics of subgroup with or without grade 2/3 renal function deterioration at P12. I was confused that the P-value here (in this table) was calculated by the Student's t-test and the Mann-Whitney U test for continuous variables/the chi-square test or Fisher's exact test for categorical data to check baseline difference between subgroups; "Or" by univariate logistic regression analysis? I suggest that authors should show another table for data of univariate logistic regression analysis for each predictive factors and then recheck multivariate logistic regression analysis. 2. In table 1, because many patients usually has abnormal liver function before treatment, FIB-4 might be influenced by hepatitis. I suggest "advanced liver fibrosis" might be replaced by "FIB-4 score higher than 3.25". 3. In table 1, HCC history means curative or inactive or stable status of HCC. Maybe authors exclude these patients to avoid some confounding effects. 4. In table 2, the odds ratio (OR) of ACEI/ARB was 2.476 (P=0.048) and the OR of BL NGAL was just 1.033 (P=0.045). ACEI/ARB had the higher weight for grade 2/3 renal function deterioration. If possible, authors could exclude patients using the medications associated with renal function (in table 1, ACEI/ARB, diuretics, NSAID) to clarify the effect of BL NGAL. 5. In Figure 3 & 4, the dynamic change of NGAL might be negatively associated with the dynamic change of eGFR from BL to P12, for patients with eGFR rank 1 and 2. This phenomenon was also found while focusing on SOF user. Therefore, these findings demonstrated the dynamic change of NGAL might reflect the dynamic changes of renal function. Maybe, authors could add the dynamic change of NGAL as one of predictive factors for analysis. As for BL NGAL, it should recheck by univariate/multivariate logistic regression analysis. Reviewer #2: This retrospective study was aimed to investigate the changes in eGFR and the role of neutrophil gelatinase-associated lipocalin (NGAL) in CHC patients receiving DAA, including nonSOF- and SOF-based regimens. Although it is interesting, some concerns are needed to be clarified. 1. Since SOF might be related to renal injury via drug-induced tubulointerstitial nephritis, the proportion of SOF-based DAA users should be added in Table 1. 2. Factors associated with grade 2/3 renal function deterioration in CHC patients receiving DAA at P12 in nonSOF-based and SOF-based DAA users may be analyzed in another two tables, respectively. The cut -off of variables, including age, BL NGAL, should be offered in Table 2. 3. Page 16, line 3, “The levels of NGAL at the BL, EOT, and P12 were all significantly different between nonSOF- and SOF-based DAA users (P = 0.011, 0.024, and 0.037, respectively). Please add a figure. 4. Page 21, line 6, “Although we found that an increase in NGAL was significant at P12 by SOF-based DAA, the values were still within the normal range”. What is the normal range of NGAL? 5. Page 22, “Fig 4. The eGFR and NGAL changes from the BL, EOT to P12 in different BL eGFR ranks in CHC patients receiving DAA therapy. a. eGFR; b. NGAL” should be in “3. Results”. ****** 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". 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Revision 1
20 Jul 2021 Author Response Reviewer #1: Authors proposed neutrophil gelatinase-associated lipocalin partly reflects the dynamic changes of renal function among CHC patients receiving DAA. It would give another point of view for clinical daily practice. I have several questions as below. 1. In table 1, authors showed baseline characteristics of subgroup with or without grade 2/3 renal function deterioration at P12. I was confused that the P-value here (in this table) was calculated by the Student's t-test and the Mann-Whitney U test for continuous variables/the chi-square test or Fisher's exact test for categorical data to check baseline difference between subgroups; "Or" by univariate logistic regression analysis? I suggest that authors should show another table for data of univariate logistic regression analysis for each predictive factors and then recheck multivariate logistic regression analysis. Response: 1. As we mentioned in the method, the P value in Table 1 was calculated by using the Student’s t-test and the Mann-Whitney U test for continuous variables and the chi-square test or Fisher’s exact test for categorical data, as appropriate. 2. In order to avoid the confusion about the statistical method, we decided to use the univariate logistic regression analysis according to your suggestion (Table 1, Page 11-13, Line 194-196). We also revised the method (Page 10, Line 168-171). Abstract was also revised (Page 3, Line 42-46). 3. The final multivariate logistic regession showed the same results (Table 2, Page 15, Line 224-230). The predictive factors were age, gender, ACEI/ARB use and BL NGAL. 2. In table 1, because many patients usually has abnormal liver function before treatment, FIB-4 might be influenced by hepatitis. I suggest "advanced liver fibrosis" might be replaced by "FIB-4 score higher than 3.25". Response: Thank you for your comment. In this study, the advanced liver fibrosis was diagnosed by an FIB-4 score higher than 3.25 or radiologic cirrhosis. The cutoff value of 3.25 was based on the metaanlysis study and total 2,297 HCV-positive paitinets regarding the liver function were included. (Chou R, Wasson N. Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review. Ann Intern Med 2013;158:807–820.) The sensertivity was 55% and sepecificity was 92%. Besides, according to EASL recommendations on treatment of hepatitis C, FIB-4 is generally available, simple and inexpensive, and reliable non-invasive method to assess liver disease severity prior to therapy. [J Hepatol. 2020;73(5):1170-218]. We marked the definition of advanced liver fibrosis in footnote of the Table 1 (Page 13-14, Line 203-206). 3. In table 1, HCC history means curative or inactive or stable status of HCC. Maybe authors exclude these patients to avoid some confounding effects. Response: 1. Thank you for your comment. We tried to exclude patients with HCC history (n=37, 16% ) and analyzed their variables. After univariate logistic regression and multivariate analyses, baseline NGAL (OR: 1.054; CI: 1.017–1.092; P= 0.004) was still predictive factor for grade 2/3 renal funtion deterioration. 2. In the logistic regression analysis, the more variables we put in our model, the greater the sample size must be. The sample size was markedly decreased after we exlcued those paitnets with HCC history (n=37, 16%) and it casues some factors become nonsignificant. Hence, we wanted to maintain original analyses and keep HCC history as one of variables. 4. In table 2, the odds ratio (OR) of ACEI/ARB was 2.476 (P=0.048) and the OR of BL NGAL was just 1.033 (P=0.045). ACEI/ARB had the higher weight for grade 2/3 renal function deterioration. If possible, authors could exclude patients using the medications associated with renal function (in table 1, ACEI/ARB, diuretics, NSAID) to clarify the effect of BL NGAL. Response: 1. It’s another good point to remove the effect of nephrotoxic medications by excluding these variables from original analysis. After we excluded patients taking nephrotoxic agents (n= 63, 27%), multivariate analyses revealed age (OR: 1.049; CI: 1.012–1.087; P= 0.010) and gender (OR: 2.363; CI: 1.144–4.877; P= 0.020) were predictive factors for grade 2/3 renal funtion deterioration. The decrease of sample size cause the baseline NGAL become nonsignificant factor. 2. Subgroup analysis may be interesting if the study included more patient number. If the number is limited, it seems reasonable to adjust those factors in multivariate analyses. As previous reason, we thought the role of baseline NGAL may be better understood under larger sample size. Furthermore, to have these variables (ACEI/ARB, diuretics, NSAID) in our investigation may be helpful in realizing the roles of thses nephrotoxic medications in the renal function of CHC patients using DAA therapy. Thank you very much. 5. In Figure 3 & 4, the dynamic change of NGAL might be negatively associated with the dynamic change of eGFR from BL to P12, for patients with eGFR rank 1 and 2. This phenomenon was also found while focusing on SOF user. Therefore, these findings demonstrated the dynamic change of NGAL might reflect the dynamic changes of renal function. Maybe, authors could add the dynamic change of NGAL as one of predictive factors for analysis. As for BL NGAL, it should recheck by univariate/multivariate logistic regression analysis. Response: Thank you for your reminder. 1. Althrough the decrease of eGFR was noted in paitnets with eGFR rank 1 and 2, the serum level of NGAL showed no significant differences from BL to P12 (Figure 4). The dynamic changes of NGAL were not negatively associated with the dynamic change of eGFR from BL to P12 for the patients with baseline rank 1 and 2 renal function. We think the values of eGFR and NGAL were not clearly demonstrated under previous versions of figure due to smaller font size. Hence, we provided newer figures in order to improve the legibility. 2. For the SOF user, the dynamic change of NGAL might be negatively associated with the dynamic change of eGFR from BL to P12 (Figure 3). But the associations between eGFR and NGAL changes were not statistically significant and they were shown in the following table. P12-BL EOT-BL P12-EOT eGFR (mean±SD) -2.02±10.44 -2.52±9.87 0.49±9.33 NGAL (mean±SD) 0.73±2.99 0.29±2.47 0.44±3.36 Linear correlation R = -0.144 , P =0.131 R = 0.007 , P =0.939 R = -0.052 , P =0.585 3. As to the dynamic change of NGAL as possible predictive factor, we tried to analyze the difference between NGAL (EOT) and NGAL (BL) as a variable for those with or without grade 2/3 renal function deterioration in the following table. We found the dynamic change between EOT and BL or P12 and BL would not become a significant predictive factor after univariate logistic regression analyses. Hence, it seemed that the dynamic change of NGAL plays no role in predicting the renal function change. Variable All patients (n = 232) With grade 2/3 deterioration (n = 62) (26.7%) Without grade 2/3 deterioration (n = 170) (73.3%) P-value# Difference between NGAL (EOT) and NGAL (BL) 0.04±2.91 -0.26±2.37 0.14±3.08 0.346 Difference between NGAL (P12) and NGAL (BL) 0.39±3.41 0.29±3.74 0.43±3.29 0.772 Reviewer #2: This retrospective study was aimed to investigate the changes in eGFR and the role of neutrophil gelatinase-associated lipocalin (NGAL) in CHC patients receiving DAA, including nonSOF- and SOF-based regimens. Although it is interesting, some concerns are needed to be clarified. 1. Since SOF might be related to renal injury via drug-induced tubulointerstitial nephritis, the proportion of SOF-based DAA users should be added in Table 1. Response: The proportion of nonSOF-based and SOF-based users were shown in table 1 (Page 12, table 1, the variable “Sofosbuvir-based”). There was a total of 112 (48.3%) SOF users. Of these patients, 33 (53.2%) were in grade 2/3 renal function deterioration group and 79 (46.5%) were in the group without grade 2/3 deterioration (P=0.363). Thank you very much. 2. Factors associated with grade 2/3 renal function deterioration in CHC patients receiving DAA at P12 in nonSOF-based and SOF-based DAA users may be analyzed in another two tables, respectively. The cut -off of variables, including age, BL NGAL, should be offered in Table 2. Response: 1. Factors associated with grade 2/3 renal function deterioration were different in nonSOF and SOF-based users. Therefore, we showed the new tables in supplement materials to demonstrate the difference between nonSOF (n= 120) and SOF-based (n=112) DAA users. The predictive factors of nonSOF users (n= 120) were gender (OR:3.161; CI: 1.150–8.686; P=0.026), fatty liver (OR: 4.684; CI: 1.689–12.990; P=0.003), and hyperlipidemia (OR:9.401; CI:1.106-7.333; P=0.002). The basline NGAL has the trend associated with the grade 2/3 renal function deterioration (P=0.05). The ACEI/ARB users (OR:3.276; CI: 1.008–10.647;P=0.049) was the only predective factor for SOF users (n=112). The possible mechanisms to explain different predictive factors of grade 2/3 renal function deterioration in nonSOF and SOF DAA users are unclear and require further study to clarify it. We added this in the our result (Page 16-17, Line 257-265) and discussion (Page 21-22, Line 356-360). These tables are displayed as supplementary materials. 2. We analyzed age and BL NGAL as continuous variables in the multivariate logistic regession. Therefore, we don’t show the cut-off values in table 2. Supplement table 1. Baseline characteristics of chronic hepatitis C patients receiving DAA with or without grade 2/3 renal function deterioration at P12 in nonSOF users. Variable All patients (n = 120) With grade 2/3 deterioration (n = 29) (26.7%) Without grade 2/3 deterioration (n = 91) (73.3%) P value Baseline clinical characteristics Age (years)† 64.06 ± 10.22 67.15 ± 6.30 63.10 ± 11.03 0.043 Male (%) 41 (34.2%) 14 (48.3%) 27 (29.7%) 0.076 Fatty liver 38 (31.7%) 15 (51.7%) 23 (25.3%) 0.011 Hyperlipidemia 12 (10.0%) 7 (24.1%) 5 (5.5%) 0.008 Diabetes mellitus 26 (21.7%) 9 (31.0%) 17 (18.7%) 0.196 Hypertension 26 (21.7%) 9 (31.0%) 17 (18.7%) 0.196 eGFR ranks* 0.428 rank 1 38 (31.7%) 7 (24.1%) 31 (34.1%) rank 2 70 (58.3%) 19 (65.5%) 51 (56.0%) rank 3 12 (10.0%) 3 (10.3%) 9 (9.9%) Baseline characteristics of HCV and liver-related conditions Advanced fibrosis (%) 70 (58.3%) 19 (65.5%) 51 (56.0%) 0.396 HCC history (%) 20 (16.7%) 6 (20.7%) 14 (15.4%) 0.569 Splenomegaly (%) 37 (30.8%) 13 (44.8%) 24 (26.4%) 0.069 Ascites (%) 1 (0.8%) 0 (0.0%) 1 (1.1 %) 1.000 Baseline HCV viral load (IU/mL)† 6.10Log ± 0.86Log 5.86Log ± 1.20Log 6.17Log ± 0.71Log 0.512 HCV genotype 1 (%) 110 (91.7%) 26 (89.7%) 84 (92.3%) 0.703 Baseline medications associated with renal function ACEI/ARB users 12 (10.0%) 4 (13.8%) 8 (8.8%) 0.481 Diuretics users 2 (1.7%) 0 (0.0%) 2 (2.2%) 1.000 NSAID users 21 (17.5%) 5 (17.2%) 16 (17.6%) 1.000 Baseline laboratory data Baseline NGAL (ng/ml) † 17.55 ± 9.55 20.59 ± 10.32 16.58 ± 9.14 0.042 ALT(U/L)† 83.63 ± 72.30 99.21 ± 99.57 78.66 ± 61.02 0.498 AST(U/L)† 60.55 ± 62.40 73.79 ± 86.03 56.33 ± 52.65 0.406 Albumin (g/dl) † 4.27 ± 0.30 4.22 ± 0.29 4.29 ± 0.30 0.222 Total bilirubin (mg/dl) † 0.73 ± 0.30 0.78 ± 0.32 0.71 ± 0.29 0.399 eGFR (ml/min/1.73m2)† 80.66 ± 15.93 78.72 ± 13.99 81.28 ± 16.52 0.274 Hb† (gm/dL) 13.67 ± 1.48 13.71 ± 1.54 13.65 ± 1.46 0.688 Prothrombin time (INR)† 1.02 ± 0.05 1.04 ± 0.06 1.01 ± 0.05 0.078 e-GFR, estimated glomerular filtration rate; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; NSAID, nonsteroidal anti-inflammatory drugs; NGAL, neutrophil gelatinase-associated lipocalin; ALT, alanine aminotransferase; AST, aspartate aminotransferase; INR, international normalized ratio rank 1: > 90 ml/min/1.73 m2, rank 2: 60-90 ml/min/1.73 m2, rank 3: 30-60 ml/min/1.73 m2; †Data are expressed as mean±SD. Supplement table 2. Baseline characteristics of chronic hepatitis C patients receiving DAA with or without grade 2/3 renal function deterioration at P12 for SOF users. Variable All patients (n = 112) With grade 2/3 deterioration (n = 33) (26.7%) Without grade 2/3 deterioration (n = 79) (73.3%) P value Baseline clinical characteristics Age (years)† 63.98 ± 11.14 65.82 ± 10.09 63.21 ± 11.52 0.255 Male (%) 42 (37.5%) 14 (42.4%) 28 (35.4%) 0.525 Fatty liver 37 (33.0%) 8 (24.2%) 29 (36.7%) 0.271 Hyperlipidemia 6 (5.4%) 1 (3.0%) 5 (6.3%) 0.668 Diabetes mellitus 18 (16.1%) 5 (15.2%) 13 (16.5%) 1.000 Hypertension 24 (21.4%) 7 (21.2%) 17 (21.5%) 1.000 eGFR ranks 0.382 rank 1 38 (33.9%) 10 (30.3%) 28 (35.4%) rank 2 50 (44.6%) 14 (42.4%) 36 (45.6%) rank 3 24 (21.4%) 9 (27.3%) 15 (19.0%) Baseline characteristics of HCV and liver-related conditions Advanced fibrosis (%) 83 (74.1%) 26 (78.8%) 57 (72.2%) 0.637 HCC history (%) 17 (15.2%) 8 (24.2%) 9 (11.4%) 0.146 Splenomegaly (%) 34 (30.4%) 12 (36.4%) 22 (27.8%) 0.377 Ascites (%) 4 (3.6%) 2 (6.1%) 2 (2.5 %) 0.580 Baseline HCV viral load (IU/mL)† 5.88Log ± 1.08Log 5.87Log ± 1.10Log 5.88Log ± 1.08Log 0.924 HCV genotype 1 (%) 44 (39.3%) 17 (51.5%) 27 (34.2%) 0.095 Baseline medications associated with renal function ACEI/ARB users 13 (11.6%) 7 (21.2%) 6 (7.6%) 0.054 Diuretics users 9 (8.0%) 4 (12.1%) 5 (6.3%) 0.445 NSAID users 13 (11.6%) 2 (6.1%) 11 (13.9%) 0.339 Baseline laboratory data Baseline NGAL (ng/ml) † 14.54 ± 8.20 15.73 ± 9.27 14.05 ± 7.72 0.612 ALT(U/L)† 89.80 ± 78.38 87.70 ± 63.70 90.67 ± 84.11 0.532 AST(U/L)† 62.93 ± 46.57 66.06 ± 45.85 61.62 ± 47.10 0.491 Albumin (g/dl) † 4.12 ± 0.41 4.07 ± 0.45 4.14 ± 0.39 0.650 Total bilirubin (mg/dl) † 0.85 ± 0.48 0.87 ± 0.44 0.84 ± 0.50 0.559 eGFR (ml/min/1.73m2)† 77.10 ± 19.54 74.41 ± 19.31 78.22 ± 19.65 0.330 Hb† (gm/dL) 13.32 ± 1.75 13.28 ± 1.52 13.34 ± 1.85 0.959 Prothrombin time (INR)† 1.04 ± 0.08 1.05 ± 0.08 1.04 ± 0.08 0.529 e-GFR, estimated glomerular filtration rate; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; NSAID, nonsteroidal anti-inflammatory drugs; NGAL, neutrophil gelatinase-associated lipocalin; ALT, alanine aminotransferase; AST, aspartate aminotransferase; INR, international normalized ratio rank 1: > 90 ml/min/1.73 m2, rank 2: 60-90 ml/min/1.73 m2, rank 3: 30-60 ml/min/1.73 m2; †Data are expressed as mean±SD. Supplement table 3. Patient factors associated with grade 2/3 renal function deterioration in chronic hepatitis C patients receiving DAA at P12^ for nonSOF and SOF-based DAA users. Odds Ratio (95% CI) P value NonSOF-based DAA users Sex Female Male 1.000 3.161 (1.150–8.686) 0.026 Fatty liver No Yes 1.000 4.684 (1.689–12.990) 0.003 Hyperlipidemia No Yes 1.000 9.401 (2.268–38.959) 0.002 BL NGAL 1.051 (1.000–1.104) 0.05 SOF-based DAA users ACEI/ARB users No Yes 1.000 3.276 (1.008–10.647) 0.049 ^Adjusted for age, sex, variables with P < 0.1 from supplement table 1: fatty liver, hyperlipidemia, splenomegaly, BL NGAL and PT INR and from supplement table 2: GT1 and ACEI/ARB users for nonSOF users and SOF users, respectively ; factors reported to be associated with renal injury: baseline renal disease, DM, HTN, liver disease (advanced fibrosis), ACEI/ARB users, diuretics users, and NSAID users were also considered in multivariate analysis. 3. Page 16, line 3, “The levels of NGAL at the BL, EOT, and P12 were all significantly different between nonSOF- and SOF-based DAA users (P = 0.011, 0.024, and 0.037, respectively). Please add a figure. Response: Thank you for your commnet. The figure has been revealed as figure 3b. We also provided new figures for better legibility and added the footnote after this sentence (Page 16, line 257). 4. Page 21, line 6, “Although we found that an increase in NGAL was significant at P12 by SOF-based DAA, the values were still within the normal range”. What is the normal range of NGAL? Response: Thank you for your reminder. We showed the normal range of NGAL in the page 9, method paragraph 2.4 and line 163-164. We added this normal range again in Page 21, line 356 for better readability. 5. Page 22, “Fig 4. The eGFR and NGAL changes from the BL, EOT to P12 in different BL eGFR ranks in CHC patients receiving DAA therapy. a. eGFR; b. NGAL” should be in “3. Results”. Response: Thank you for your reminder. We have corrected it (Page 18, line 286-287). Thank you very much. Attachments Attachment Submitted filename: Response to Reviewers.docx* https://doi.org/10.1371/journal.pone.0256505.r002
9 Aug 2021 Decision Letter - Chen-Hua Liu, Editor Neutrophil gelatinase-associated lipocalin partly reflects the dynamic changes of renal function among chronic hepatitis C patients receiving direct-acting antivirals PONE-D-21-15486R1 Dear Dr. Chen, 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, Chen-Hua Liu Academic Editor PLOS ONE 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 ******** 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 ****** 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: The authors answered and revised the manuscript according to my suggestions. I endorse publication of the manuscript. Reviewer #2: (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 #1: No Reviewer #2: Yes:** Wei-Yu Kao https://doi.org/10.1371/journal.pone.0256505.r003
Formally Accepted
18 Aug 2021 Acceptance Letter - Chen-Hua Liu, Editor PONE-D-21-15486R1 Neutrophil gelatinase-associated lipocalin partly reflects the dynamic changes of renal function among chronic hepatitis C patients receiving direct-acting antivirals Dear Dr. Chen: 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. Chen-Hua Liu Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0256505.r004

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