PONE-D-24-34834Renin-angiotensin-aldosterone system variations in type 2 diabetes mellitus patients with different complications: implications for glucose metabolismPLOS ONE

Dear Dr. Yue,

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.

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ACADEMIC EDITOR

The authors provide a detailed narrative of RAAS activation both in T2DM patients as well as different conditions related to T2DM. Their data confirms that the activation status of the RAAS system differed among T2DM patients with different complications, highlighting the need for clinical differentiation.

General comments

There are several grammatical and punctuation errors throughout the manuscript, which can be revised with the expertise of a language editor.

Please also address the following:

Submission page: Corresponding Author; Order of Authors: The is abbreviated incorrectly. Please correct to abbreviated term “ph.D” to “PhD”; and “CHINA” to “China”.

Abstract

Change “Result” to “Results”; “cross” to “across”.

“Key words” should be one word, i.e., “Keywords”.

Introduction

• Page 1: “The global diabetic population has surged to 537 million and is projected to escalate to 642 million by 2040” - Does this statistic represent both Type 1 and Type 2 diabetes, or just Type 2 diabetes? Clarification on this point would help readers understand the scope of the study.

• Page 2-3: Revise the grammar or reword the sentence “China has witnessed a significant increase in diabetes prevalence in recent years, with the highest number of people with diabetes [3, 4].

• Please provide statistics to support this statement. Additionally, is this true for both Type 1 and Type 2 diabetes?

• The statement “Research indicates that the activation status of the renin-angiotensin aldosterone system (RAAS) undergoes alterations in diabetic patients with various complications [9-11]” Please specify if this is for Type 1 or Type 2 diabetic patients or inclusive of both types.

• Please change “rate” to “rates”.

• Please insert “levels” after “elevated HbA1c” .

• Please change “blood glucose control deteriorated” to “blood glucose levels deteriorated”

• The statement “A comprehensive study with a substantial sample size revealed a wide distribution of renin activity in hypertensive patients, particularly among those with diabetes [19].” Should be expanded to include sample size and more data to enhance the relevance

• Please add reference to support this statement “Accurate measurement of renin levels not only helps evaluate patient compliance with prescribed therapies but also assists clinicians in optimizing treatment strategies.”

Method

•Study subjects: Be consistent and use two decimal places for “average age of 52.3 years”

•Verbal consent is indicated, however written informed consent is most applicable, especially when dealing with personal and sensitive health data. Was verbal consent the only form of consent? If so, please clarify why this was deemed appropriate. Also, consider adding whether the study followed any privacy guidelines, such as anonymizing data.

•Why are individuals undergoing treatment with aldosterone receptor antagonists and direct renin inhibitors excluded? Are these treatments expected to interfere with RAAS measurements? A brief justification would clarify this decision so that other readers understand.

•The control group consists of “46 healthy individuals.” How was the absence of diabetes or hypertension verified? Were any potential confounders (such as family history of diabetes or hypertension) accounted for when selecting the control group?

•Regarding the statement “The individuals rose in the morning in a fasting, non-recumbent position... Blood samples were then obtained via the cubital vein.”: Was there any particular reason for the 2-hour non-recumbent period before blood sampling? A brief justification for this protocol would be useful. If the timing or posture before blood sampling is crucial for measuring RAAS activity, briefly explain its importance.

•The study was approved by the Ethics Committee, however, the approval number is not provided: Please include. State how patient data was anonymized or protected during the study.

•Ensure consistency in terminology. For example, “participants” and “patients” are used interchangeably. Stick to one term for the study population.

•Consider move the subsection “Group and Subgroup” before the inclusion/exclusion criteria. This will give readers a clear understanding of the study's design before reviewing the criteria.

•Consider including a flow diagram that summarizes the patient selection process and subgroup classification.

•Please be consistent in reporting P-values (e.g. rounding to 2 decimal units)

•Method of detection: Please add manufacture and manufacturing country in brackets after “AutoLumo A2000 Plus”

Results

“Result” should be changed to “Results”.

Section 3.2 – State clearly what trend (i.e., between which complications or variables) is depicted in the statement “The concentrations of ALD and REN exhibited a consistent trend, while ARR showed an opposite trend to the REN concentration (Fig 1)”

Table 1: Please capitalize “age” and write “Kg/m2” as “kg//m2”; add a space between “Diabetic duration” and “(M)”.

Under “Complication subgroup analysis of the RAAS system”: Please change “cross” to “across”.

Figure 1

The analytes are reported in different units of measurement (pg/ml, ng/dL and ng/L). Use a uniform unit of measurement for all analytes to enable easier trend detection.

Caption - “*** P<0.0017”: Suggest changing p-value level to p<0.005.

Include the means ± standard deviation in legend as it is difficult to ascertain this data from the graphs.

Discussion

Please change “Discuss” to “Discussion”.

Page 21: Add “A” before “Previous study” and insert a reference for this study.

Page 23 –Consider adding study details, particularly sample size to this sentence “A comprehensive study with a substantial sample size revealed a wide distribution of renin activity in hypertensive patients, particularly among those with diabetes [19].”

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We look forward to receiving your revised manuscript.

Kind regards,

Nalini Govender, Ph.D

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: Partly

Reviewer #2: Yes

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

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 manuscript, Baohong et al. addressed the link beetwen RAAS activation and glucose metabolism in patients suffering from different T2DM complications.

A large array of observations, in the current literature, shows that dysregulation of RAAS in the metabolic syndrome favors type 2 diabetes. Therefore, the concept of a dual axis of RAAS regarding glucose homeostasis has emerged.

A large body of evidence had already shown that RAAS blockade improves glucose homeostasis and prevents diabetes in patients suffering from the metabolic syndrome, but, currently, drugs targeting RAAS are not given for the purpose of preventing diabetes in patients suffering from metabolic syndrome.

The authors provide a thorough description of RAAS activation both in T2DM patients and in different conditions related to T2DM ( hypetersion, nephropathy, ketoacidosis) which is pretty innovative. Anyhow, in my opinion, in order to make this manuscript more appealing, the authors should include in the analysis the effects of both SGLT2-inhibitors and GLP1 -RA on RAAS. Finally, it would be convenient to mention how ARR interpretation, because of drug interference, could affect clinical practice.

Reviewer #2:  Well written and scientifically sound manuscript.

Extensive technical data supports the conclusion as each set of analyzed data is explained in the results section, either tabulated and/or projected with graphical statistics.

Statistical analysis conforms to the typical and most appropriate for the dataset.

The flow of the manuscript is logical and ordered.

MINOR REVISIONS

Methods Section

Study subject

Discrepancy in total sample size and allocated subgroup

Total sample size should be n=237 (Experimental group and controls). Sample size stated (subheading 2.1) involved a retrospective selection of 191 patients diagnosed with T2DM (Total n=151, but subgroup DMHT=151, DMNT=40 and Controls=46)

Perhaps including the sample number per subgroups (under subheading 2.3) will also assist.

Include ethics number under sub heading 2.2 (end of paragraph)

Results

Was a normality test performed initially to determine if sample population was parametric or non-parametric in order to settle with using mean and SD or SEM and interquartile range to represent your data.

In Table 1 and Table 2, p values should not technically be represented as zero (especially when testing a hypothesis). Perhaps represent as p < 0.0001.

p value should be in lowercase and in italics throughout the manuscript.

The normal peripheral blood concentration ranges for normotensive (control) patients:

Angiotensin II = 5 to 35pg/ml

Renin = 0.7 to 3.3ng/ml/hr

Aldosterone = 7 to 30ng/dL

Does your control group conform to these ranges or are you using alternate referenced ranges?

Discussion

“Conversely, the absence of such a reaction in DNK indicates impaired juxtaglomerular cell function, leading to no renin release even under dehydration stimulation” – consider rephrasing as your data suggests that renin was detected but concentration levels were decreased.

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Reviewer #1: Yes:  Roberta Poli MD PhD

Reviewer #2: No

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Renin-angiotensin-aldosterone system variations in type 2 diabetes mellitus patients with different complications and treatments: implications for glucose metabolism

PONE-D-24-34834R1

Dear Dr. Yue,

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.

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Kind regards,

Nalini Govender, Ph.D

Academic Editor

PLOS ONE

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