PONE-D-24-04153High ferritin is associated with liver and bone marrow iron accumulation: effects of 1-year deferoxamine treatmentPLOS ONE

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Reviewers' comments:

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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: Partly

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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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: In this very high-quality article, the authors analyze prospectively with R2* relaxometry both liver, heart, spine bone marrow and iliac bone marrow iron content together with bone marrow biopsy in a cohort of hemodialysis patients highly iron overloaded treated with Deferoxamine, an IV classical iron chelator given at the end of dialysis sessions. They elegantly show that heart was speared in these patients and that iron deposits are significantly reduced in liver and bone barrow (at spine and crest iliac sites). This notion of benefit of iron chelation by Deferoxamine in dialysis associated iron overload in the modern ESA era appears clearly new with an important clinical translation.

I suggest some modifications to allow this article to reach the high standard of publications of Plos one:

-Title and running title :

Title :the readers do not imagine that the study focus on dialysis patients ; it seems wise to add the term dialysis as follows : High ferritin is associated with liver and bone marrow iron accumulation : effects of 1- year deferoxamine treatment “in hemodialysis associated iron overload”

Running Title : Liver and bone marrow iron accumulation “in dialysis”

-Line 103-104 : Since most of these studies have been performed before EPO discovery, I would add to the original sentence : “However, few studies have reported the use of DFO to treat iron overload in patients with CKD, mostly in the pre-ESA era”13-15

-Line 132-142 : Normal values of the different parameters are best given in the tables (left column) instead of the text.

-Pages 7 and 8: did the authors find a correlation between LIC and monthly dose of IV iron; what were the correlation between spine R2*water and Liver R2* water, and between ferritin and spine R2*water ?

-Table 2, page 10 : For liver iron concentration given as R2* and T2* , authors also give LIC values in mgFe /g of dry weight; they also should give values of LIC in micromole Fe /g of dry weight (largely used) to allow numerous clinicians to easily understand the results. Similarly, for iliac and spine iron, iron concentration values are given as R2*values , but authors should also give values in T2* values (ms) which are largely used in the literature.

-The discussion section should include others relevant publications on this topic:

1) Carrilho P, Fidalgo P, Lima A, et al. Post-mortem liver and bone marrow iron quantification in haemodialysis patients: a prospective cohort study. EBioMedicine. 2022;77:103921. doi: 10.1016/j. 25. Ali M, Fayemi AO, Rigolosi R, Frascino J, Marsden T, Malco ebiom.2022.103921. This post-mortem study comprising immediate post-mortem specimen in 21 hemodialysis Portugese patients showed the parallelism between the bone marrow and liver compartments.

2) Rostoker G, Dekeyser M, Francisco S, et al. Relationship between bone marrow iron load and liver iron concentration in dialysis-associated haemosiderosis. EBioMedicine. 2024 Jan;99:104929. doi:10.1016/j.ebiom.2023.104929. Epub 2023 Dec 20.

This MRI-R2* relaxometry study (of liver, spleen and spine) recently published confirms and extends, in a cohort of 152 alive patients treated by hemodialysis with iatrogenic iron overload in about one half of them, the conclusions of the recent autopsy study by Carrilho et al. Both studies demonstrate that the paradoxical discrepancy observed by Ali et al. in the pre-ESA era (Ali M, Rigolosi R, Fayemi AO,et al. Failure of serum ferritin levels to predict bone-marrow iron content after intravenous iron-dextran therapy. Lancet. 1982;1(8273):652-655. doi: 10.1016/S0140-6736(82)92204-8.) between the bone marrow and hepatic iron compartments in overloaded dialysis patients has totally disappeared in the current modern ESA era, and that bone marrow iron now rather follows a similar kinetic, as traditionally seen in secondary hemosiderosis.

3) At least 3 publications have documented the use of the oral chelator Deferasirox (probably less safe than Deferoxamine) in dialysis patients suffering from iron overload (article 3-1 having MRI monitoring)

3-1) Bekhechi W, Chiali H, Khelil L, Sari-Hamidou R, Benmansour M. Hemosiderosis in chronic dialysis patients: Monitoring the response to deferasirox by quantitative hepatic magnetic resonance imaging. Hemodial Int. 2023 Jul;27(3):270-277. doi: 10.1111/hdi.13081. Epub 2023 Mar 30.

3-2) Yii E, Doery JC, Kaplan Z, Kerr PG. Use of deferasirox (Exjade) for iron overload in peritoneal dialysis patients.Nephrology (Carlton). 2018 Sep;23(9):887-889. doi: 10.1111/nep.13389.

3-3) Chen CH, Shu KH, Yang Y Long-term effects of an oral iron chelator, deferasirox, in hemodialysis patients with iron overload..Hematology. 2015 Jun;20(5):304-10. doi: 10.1179/1607845414Y.0000000199. Epub 2014 Sep 9.PMID: 25200910

Reviewer #2: This is an interesting paper on the use of DFO in patients with high ferritin and chronic kidney disease. The analyses seem to be largely well-performed, but there is a lack of information on the design of the study.

In terms of design it would help to

a) explain why 28 patients was considered sufficient here - was there a power calculation done, and what was the primary outcome in the study? The flowchart should be introduced in line 157 and the inconsistency between 70 and 95 as the starting point explained here.

b) In terms of time of study, it makes sense to separate recruitment and follow-up - it would appear to be 1 year recruitment and then 1 year follow-up but this is not very clear.

When analysing the data, they are of course paired, so it would help to give the change score distribution here with mean and sem or equivalent as this is what drives the p-value and it helps to understand the scale of the difference as this is probably more important than the significance level from a clinical point of view.

Figure 5 is more precise as a table as numbers are not given here. A table can also give the extent of the data as paired rates for McNemars test etc.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-04153R1High ferritin is associated with liver and bone marrow iron accumulation: effects of 1-year deferoxamine treatment in hemodialysis-associated iron overloadPLOS ONE

Dear Dr. Nunes,

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.

Please submit your revised manuscript by Jul 08 2024 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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Aleksandra Klisic

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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)

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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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

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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: This revised version has considered reviewers’ comments and advice ad seems suitable for publication in PLOS ONE. One minor remark: authors please explain the acronym TMV.

Reviewer #2: Thank you for your previous responses. I would request one chance to Table 4 - this is presented as if the data are not paired - please instead cross tabulate the values at the different timepoints- the data currently presented is therefore in the marginal data, but one can see the paired data allowing clarity of testing.

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Reviewer #1: No

Reviewer #2: No

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High ferritin is associated with liver and bone marrow iron accumulation: effects of 1-year deferoxamine treatment in hemodialysis-associated iron overload

PONE-D-24-04153R2

Dear Dr. Nunes,

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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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,

Aleksandra Klisic

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: 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 #2: (No Response)

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

Reviewer #2: (No Response)

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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)

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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)

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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)

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Reviewer #2: No

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