PONE-D-24-33836A Retrospective Analysis of Prenatal Genetic Results in Fetal HydronephrosisPLOS ONE

Dear Dr. jin,

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.

Thank you for submitting this interesting manuscript, and I believe it adds value to the literature. This manuscript would be considered for acceptance after the questions raised by the editor and the reviewers are addressed.

Editors' comments-

The fetal anomaly detection rate was 10% with CMA in mild hydronephrosis and it was 37.21% in moderate to severe hydronephrosis based on the Table 4, but your text says opposite. Please correct that. Please change your wording of Severe and moderate to " moderate to severe".

Please add the meaning of VUS to the table's legend on the table 2

It appears that abnormal CMA results were noted in all fetuses with karyotype abnormalities. CMA was abnormal in another 12 cases with fetal hydronephrosis. Would recommend adding further discussion whether the author recommends CMA should potentially replace karyotyping or should CMA be done in fetuses with hydronephrosis in conjunction with fetal karyotyping. It would be of additional help if you could go over the risks associated with amniotic fluid collection and whether that procedure is justified or not.

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Kind regards,

Prathap kumar Simhadri, MD

Academic Editor

PLOS ONE

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Additional Editor Comments:

Thank you for submitting this interesting manuscript, and I believe it adds value to the literature. This manuscript would be considered for acceptance after the questions raised by the editor and the reviewers are addressed.

Editors' comments-

The fetal anomaly detection rate was 10% with CMA in mild hydronephrosis and it was 37.21% in moderate to severe hydronephrosis based on the Table 4, but your text says opposite. Please correct that. Please change your wording of Severe and moderate to " moderate to severe".

Please add the meaning of VUS to the table's legend on the table 2

It appears that abnormal CMA results were noted in all fetuses with karyotype abnormalities. CMA was abnormal in another 12 cases with fetal hydronephrosis. Would recommend adding further discussion whether the author recommends CMA should potentially replace karyotyping or should CMA be done in fetuses with hydronephrosis in conjunction with fetal karyotyping. It would be of additional help if you could go over the risks associated with amniotic fluid collection and whether that procedure is justified or not.

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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: Partly

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

Reviewer #4: 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: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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5. Review Comments to the Author

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Reviewer #1:  my review comment

1. The aim of this research is to open up opportunities for more detailed examinations to carry out more in-depth follow-up examinations when an examination karyotype appears normal

2. More advanced technology is needed for more precise diagnostics and perhaps if it is used more widely and at affordable costs it will be more useful for making a more accurate diagnosis

3. This research also shows in research methods that the role of ultrasound imaging is still needed to determine abnormalities in initial screening, and this is quite important because so far ultrasound tools can be used widely in the medical field

4. Statistical methods are adequate because comparisons are all that is needed in this research

5. The results section is adequate, but it would be advisable to make the table look easier to evaluate by using a graph or diagram method.

6. Patients who continue pregnancy, my suggest should be explained about postpartum mortality or morbidity because it is an important source of information about the lethality of hydronephrosis.

7. In the discussion,

-it is possible to discuss in more depth about isolated and non-isolated anomalies because it is important whether hydronephrosis is part of a syndrome or not, this must be clarified more because it helps with specific classification if there is a tendency to be included in a syndrome. such as in one of the cases found in holoprosencephal or in cases accompanied by VSD.

-the discussion section also does not explain enough, for example the relationship between thickening of NT 3.2 and hydronephrosis. This is actually additional interesting information because so far many clinicians have associated thickening of the NT with trisomy 21.

8. The limitation of this research is that the data is sensitive enough that it cannot be accessed. This is a limitation of this research. However, this research helps to open up the many possibilities and very varied abnormalities in chromosomes or gene abnormalities.

maybe that's my suggestion and opinion, whatever the shortcomings, the article is very worthy because there are several things that can add strength to the suggestion for gene examination in abnormalities found macroscopically, especially in abnormalities found ultrasonographically

congratulation for authors

Reviewer #2:  Elaborate more about specific references and literature to justify main objective - early prenatal screening for fetal malformation is important for clinical prognosis.

The tables (e.g., Tables 1, 2, 3, and 4) are informative, but the data could be better integrated into the text to provide more contextual analysis. Currently, there is a lot of information about abnormal karyotypes, CNVs, and other findings, but the clinical significance of each type of abnormality could be emphasized more clearly in the discussion.

Discussion section - could benefit from being specific with study’s main objective and how the results could impact clinical practice (e.g., by suggesting recommendations for when to use CMA in routine prenatal screening).

Conclusions - Provide specific recommendations for clinicians, particularly about when to use CMA as opposed to traditional karyotyping.

There are multiple limitations like sample size, retrospective design, No controls, No long term follow ups and should be mentioned clearly

Was there any ethical concerns regarding how the results influence decision-making about pregnancy continuation. Further discussion on the impact of the findings on parental decisions and counseling could be a limitation not addressed in detail

Reviewer #3:  would benefit from a stronger discussion on the implications of VUS findings and their practical significance in prenatal counseling for patients. Higher sample size would have made the study more impactful.

Reviewer #4:  This is a study that was done to evaluate the applicability of chromosomal microarrays(CMAs) in fetuses with hydronephrosis and pyelectasis.

- It is overall a good clinical study subject and well written research article

- This study is retrospective and limited sample and single center study so those are the limitations

- Few comments of couple of thigs-1st analysis that was done>>correlation analysis between renal hydronephrosis and fetal chromosomal anomalies in pathogenic variants vs VUS variants was not statistically significant. So does not support that CMAs are better than karyotypes and proves. Increasing the sample size can help us better understand if its favorable for CMAs or not

-From 2nd analysis, which included comparison of fetal anomaly detection rates with CMA in mild vs mod-severe hydronephrosis. Pathologic cases were detected by both Karyotype and CMAs as well but other variants detected by CMAs were all VUS variants, which brings us to next question of clinical utility of detecting these genes?? There were 12 fetuses that were identified with VUS variants with normal karyotypes and all of them continued pregnancy. It would be nice to see postnatal follow ups and how those babies are doing? Was hydronephrosis clinically important with those VUS variants??

-Next question to think would be--Does having multiple anomalies on scan would benefit from CMAs testing vs just isolated mild hydronephrosis clinically? Reference to that from below study.

"Prenatal chromosomal microarray analysis in 2466 fetuses with ultrasonographic soft markers: a prospective cohort study

Ting Hu 1, Tian Tian 2, Zhu Zhang 1, Jiamin Wang 1, Rui Hu 1, Like Xiao 1, Hongmei Zhu 1, Yi Lai 1, He Wang 1, Shanling Liu 3"

- How were mothers counseled from those fetuses which had VUS variants and found some anomalies on ultrasound? was genetic counseling considered?

-Also, regarding cost effectiveness? would this be cost effective?

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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A Retrospective Analysis of Prenatal Genetic Results in Fetal Hydronephrosis

PONE-D-24-33836R1

Dear Dr. jin,

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Kind regards,

Prathap kumar Simhadri, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for updating your manuscript and addressing the questions raised by the reviewers. We believe this paper adds value to the literature and it is acceptable in the current form.

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