Association between diabetes mellitus and impaired single-leg stance in patients with chronic liver disease: A cross-sectional study

Kenichi Fudeyasu; Makoto Asaeda; Toshihiro Kawae; Takuo Nomura; Yuki Nakashima; Daisuke Iwaki; Kouki Fukuhara; Takeya Araki; Haruya Ohno; Eisuke Murakami; Shiro Oka; Yukio Mikami

doi:10.1371/journal.pone.0345407

Peer Review History

Original SubmissionMarch 25, 2025
21 Apr 2025 Decision Letter - Bisher Sawaf, Editor Dear Dr. Asaeda, 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. ============================== Dear Authors, Thank you for your submission to PLOS ONE. We have now received and reviewed two detailed and constructive peer reviews. Based on the feedback, the manuscript demonstrates scientific merit and clinical relevance; however, significant revisions are needed before it can be considered for publication. In preparing your revised manuscript, please address the following key points in addition to the specific reviewer comments: Clarify and refine your hypothesis and objectives to more precisely reflect your focus on balance impairment (i.e., SLST) rather than general physical function. Revise and standardize methodological descriptions , including the FIB-4 formula, consent procedure, variable definitions, and statistical approach (e.g., normality testing, multicollinearity diagnostics, use of exact logistic regression where appropriate). Expand your discussion to contextualize the ECW/TBW findings. Clearly note its current status as a data-derived marker needing external validation, and consider integrating relevant mechanistic pathways. Ensure consistency in terminology (e.g., always use “diabetes mellitus (DM)” after first mention), abbreviation use, and statistical formatting (e.g., p-values). ============================== Please submit your revised manuscript by Jun 05 2025 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. 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'. 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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, Bisher Sawaf Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating the following financial disclosure: “This work was supported by a grant (H30-A59) from the Japanese Society of Physical Therapy and Japan Society for the Promotion of Science KAKENHI Grant Number JP19K19831.” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 3. In this instance it seems there may be acceptable restrictions in place that prevent the public sharing of your minimal data. However, in line with our goal of ensuring long-term data availability to all interested researchers, PLOS’ Data Policy states that authors cannot be the sole named individuals responsible for ensuring data access (http://journals.plos.org/plosone/s/data-availability#loc-acceptable-data-sharing-methods). Data requests to a non-author institutional point of contact, such as a data access or ethics committee, helps guarantee long term stability and availability of data. Providing interested researchers with a durable point of contact ensures data will be accessible even if an author changes email addresses, institutions, or becomes unavailable to answer requests. Before we proceed with your manuscript, please also provide non-author contact information (phone/email/hyperlink) for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If no institutional body is available to respond to requests for your minimal data, please consider if there any institutional representatives who did not collaborate in the study, and are not listed as authors on the manuscript, who would be able to hold the data and respond to external requests for data access? If so, please provide their contact information (i.e., email address). Please also provide details on how you will ensure persistent or long-term data storage and availability. 4. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. 5. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Thank you to the authors for your thoughtful and well-organized manuscript. Introduction (Lines 48–72) Line 67: Reference specific studies showing increased fall risk due to diabetic neuropathy or proprioceptive impairment. Line 71: Replace “poorer physical function” with “reduced physical function” for clarity and academic tone. Line 72: The objective could be rephrased more precisely: “to examine whether comorbid diabetes mellitus is associated with impaired balance, as measured by single-leg standing time, in patients with chronic liver disease.” Methods (Lines 74–192) Line 84: Provide justification for the opt-out consent model. Mention whether this aligns with national research guidelines for retrospective studies in Japan. Lines 96–98: There is repetition in the list of blood markers (e.g., AST, ALT, ALB) — revise to eliminate redundancy. Line 109: The FIB-4 formula includes a square root of ALT, which is not conventional. Please clarify with a reference or correct if inaccurate. Line 126: Specify whether SLST measurements had inter-rater or intra-rater reliability assessments. Lines 170–173: Confirm whether normality of distribution was assessed before choosing statistical tests like t-tests or Mann-Whitney U. If so, report those results explicitly. Results (Lines 194–295) Line 199: Consider merging etiologies with low sample size (e.g., HBV, ALD, others) or acknowledging the limited power for these subgroups. Line 243: A 0% vs. 20% SLST impairment rate is striking — discuss whether key confounders (e.g., diabetic neuropathy, medication use, or fall history) were considered or controlled. Line 282: The predictive value of ECW/TBW (AUC = 0.733, PPV = 37%) is moderate. Discuss whether combining this marker with other functional metrics (e.g., grip strength) could improve diagnostic accuracy. Discussion (Lines 297–366) Line 304: Reaffirm how this is the first study (to your knowledge) evaluating SLST in CLD populations — cite any comparable work or clarify novelty. Line 330: Address the low variance in ammonia levels (NH₃), which may explain the lack of association with SLST. Suggest this as a sample bias or a limitation of the study cohort. Line 337: Include references to prior research connecting mild overhydration or edema to proprioceptive or postural instability to support the ECW/TBW mechanism. Line 349: Recommend specific design elements for future research, e.g., prospective follow-up with diabetes duration, neuropathy scores, and functional falls data. General Suggestions Consistency: Standardize all uses of “diabetes” to “diabetes mellitus (DM)” after first mention for clarity. Abbreviations: Suggest adding a footnote or separate table listing abbreviations like ECW/TBW, ASM/BMI, KEF, etc. Statistics: Ensure consistent p-value formatting (e.g., p = 0.002). If exact p-values are unavailable, use p < 0.001 rather than zero. Reviewer #2: Introduction: - The hypothesis is stated as a general decline in “physical function” among DM patients with CLD. However, the actual analysis focuses narrowly on balance function as assessed by SLST. I suggest reframing the hypothesis to specifically address postural stability or balance-related impairment, aligning better with the operationalized outcome. Methods: - The FIB-4 formula includes a square root of ALT, which deviates from the canonical form (without transformation). This must be clarified, as it could affect the fibrosis score interpretation across studies. - SLST methodology uses the mean of both legs, but no indication is given about distributional skew or floor effects. Given that 20% of DM patients had SLST <5 seconds and non-DM had 0%, consider whether a dichotomous transformation (e.g., <5s vs ≥5s) might yield more interpretable or clinically meaningful stratification for this population. - It is unclear whether leg dominance was recorded. While cited literature claims no performance difference, individual patient-level variability may still affect balance metrics, particularly in neuromuscular-compromised cohorts. - There is no mention of multicollinearity diagnostics before entering variables into multivariate logistic regression. BMI and ECW/TBW may be collinear. Reporting variance inflation factors (VIFs) or tolerance values is recommended. Results: - The finding of 0% SLST <5s in non-DM patients vs. 20% in DM patients is striking but statistically vulnerable due to zero-cell counts. Consider whether exact logistic regression would be more appropriate than asymptotic methods here. - The AUC for ECW/TBW is 0.733 with relatively low PPV (37%) but high NPV (91.4%). This indicates that ECW/TBW may serve better as a rule-out marker than a rule-in diagnostic. The authors should address this explicitly in interpretation. Discussion (Lines 297–366) - The discussion of ECW/TBW as "subclinical edema" is compelling. However, the threshold of 0.393 is data-derived from this study and requires external validation before being used in clinical settings. This caveat should be emphasized. - There’s an opportunity here to draw connections between interstitial fluid dynamics, insulin resistance, and muscle signaling pathways, all of which are altered in CLD-DM. These links could provide a more mechanistic narrative for the ECW/TBW-SLST association. ****** 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". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . 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Revision 1
3 Jun 2025 Author Response May 28, 2025 Dr. Bisher Sawaf Academic Editor PLOS ONE Dear Editor, Thank you for your consideration of our manuscript previously titled “Chronic liver disease complicated by diabetes mellitus is associated with impaired single-leg standing in patients: a cross-sectional study” (Manuscript ID: [PONE-D-25-15349], EMID: 7be85993d2e2226f). We have carefully revised the manuscript in accordance with the editors’ and reviewers’ suggestions. A point-by-point response to each comment is provided below. All changes in the revised manuscript are highlighted in red font. We sincerely hope that our responses and revisions have satisfactorily addressed all concerns, and that the manuscript is now suitable for publication in PLOS ONE. Please note that we have updated the manuscript title to replace “Chronic liver disease complicated by diabetes mellitus is associated with impaired single-leg standing in patients: a cross-sectional study” with the more standard and academically appropriate title “Association between diabetes mellitus and impaired single-leg stance in patients with chronic liver disease: a cross-sectional study.” The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Additionally, we would like to request an update to the second affiliation of the first author, Kenichi Fudeyasu. The corrected affiliation is: 2 Department of Rehabilitation Medicine, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan. Please ensure this correction is reflected in the author list and manuscript metadata upon acceptance. We greatly appreciate the opportunity to revise our work and look forward to your response. Best regards, Makoto Asaeda Department of Rehabilitation Medicine, Hiroshima University Hospital 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan TEL: +81-82-257-5566 E-mail: asaedam@hiroshima-u.ac.jp To the Editor’s comments In preparing your revised manuscript, please address the following key points in addition to the specific reviewer comments: - Clarify and refine your hypothesis and objectives to more precisely reflect your focus on balance impairment (i.e., SLST) rather than general physical function. Response: Thank you very much for your insightful comment. In response to your suggestion, we have revised the description of the hypothesis and objective to better clarify the focus of our study, particularly highlighting the single-leg stance test (SLST) as the primary outcome. The revised text in the manuscript is as follows: (Introduction, Page 5, Lines 88–91): "We hypothesized that comorbid DM is associated with impaired balance in patients with CLD and that this decline would be evident in the single‑leg stance test (SLST) as a measurement of balance. Therefore, the aim of this study was to examine whether comorbid DM is associated with impaired SLST in patients with CLD." - Revise and standardize methodological descriptions, including the FIB-4 formula, consent procedure, variable definitions, and statistical approach (e.g., normality testing, multicollinearity diagnostics, use of exact logistic regression where appropriate). Response: Thank you very much for your important and constructive comments. In response, we have clarified several methodological aspects, including the formula for calculating the FIB-4 index, the informed consent process, variable definitions, and our statistical approach (e.g., normality testing, multicollinearity diagnostics, and use of exact logistic regression when appropriate). These revisions have been made in multiple sections of the manuscript and we have included a copy below for your reference: (Methods, Page 5, Lines 103–112): "The study was conducted in accordance with Declaration of Helsinki and the Ethical Guidelines for Medical and Health Research Involving Human Subjects enacted by the Ministry of Health, Labour and Welfare of Japan (https://www.mhlw.go.jp/content/001077424.pdf), and approved by the Ethical Review Committee of Hiroshima University Hospital (Permit No. E-583-1). All patients were verbally informed that their medical records and charts might be used for research purposes. Data were obtained during routine medical care and reviewed retrospectively. The need to obtain informed consent from the study participants was waived by the Ethical Review Committee of Hiroshima University Hospital due to the retrospective nature of the study. Patients who were eligible for this study had the opportunity to refuse to participate in the study by opting out." (Methods, Page 7, Lines 134–138): “Liver fibrosis was assessed using serum marker-based scoring systems, including the AST-to-platelet ratio index (APRI) and the fibrosis-4 (FIB-4) index [49–53]. The APRI and FIB-4 index were calculated using the following equations, APRI=(AST[IU/L]/upper limit of normal AST[IU/L])/(PLT [〖10〗^9/L] )×100 FIB-4 index=(AST[IU/L]×age [years])/(PLT [〖10〗^9/L]×√(ALT [IU/L] )) (Methods, Page 10, Lines 204–217): “All continuous variables were first subjected to the Shapiro–Wilk test to assess normality. Variables that followed a normal distribution were presented as mean (± standard deviation) and were compared between groups using the Student’s t-test. Variables that deviated from normality were expressed as median (interquartile range) and compared using the Mann–Whitney U test. Categorical variables were presented as absolute numbers and percentages and compared using the Fisher’s exact test or chi-squared test, as appropriate. An additional analysis was conducted using data from 118 patients with CLD who had comorbid DM, to identify factors associated with impaired SLST in this subgroup. Logistic regression analysis was performed with impaired SLST (< 5 s) as the dependent variable, using both univariate and multivariate models, and ORs with 95% CIs were reported. Following previous studies, KEF/weight values were multiplied by 100 and ECW/TBW values by 1000 to facilitate interpretation [66]. Multicollinearity was assessed by calculating variance inflation factors (VIFs), with values ≥ 2 considered indicative of collinearity.” - Expand your discussion to contextualize the ECW/TBW findings. Clearly note its current status as a data-derived marker needing external validation, and consider integrating relevant mechanistic pathways. Response: Thank you for these valuable suggestions. In response, we have expanded the discussion to better contextualize the significance of ECW/TBW. In particular, we have clarified that ECW/TBW is a data-derived marker that requires external validation, and we have incorporated relevant mechanistic pathways to support its interpretation. Specifically, we have made the following additions: (Discussion, Page 24, Lines 395–419): " The association between ECW/TBW and SLST in patients with CLD and comorbid DM may be explained by the interplay of multiple pathophysiological mechanisms. In liver cirrhosis, portal hypertension and lymphatic dysfunction lead to the accumulation of interstitial fluid [79, 80], resulting in pronounced lower extremity edema [81]. Such edema may impair muscle strength and proprioception, potentially leading to diminished balance capabilities [82-84]. Furthermore, CLD with comorbid DM is characterized by a significant resistance to insulin that has been linked to reductions in skeletal muscle mass and strength [85, 86]. In mice lacking insulin receptors (IR) and insulin-like growth factor-I receptors (IGF-IR) in skeletal muscles, protein catabolism is enhanced through activation of the proteasome and autophagy pathways, leading to muscle wasting and weakness. Notably, muscle atrophy is suppressed in mice deficient in Forkhead box O, indicating the critical role of IR/IGF-IR/Forkhead Box O signaling in maintaining muscle mass and strength [87]. In addition, mice lacking insulin signaling molecules such as phosphoinositide 3-kinase [88] and Akt [89] exhibit not only impaired glucose tolerance but also reductions in muscle mass and fiber diameter, further supporting the relationship between insulin resistance and muscle dysfunction. Myostatin, a myokine that strongly suppresses muscle protein synthesis, plays a key role in maintaining muscle homeostasis in accordance with anabolic myokines [90]. In patients with CLD, serum myostatin levels tend to increase as the disease progresses, potentially contributing to suppressed muscle protein synthesis [91, 92]. Taken together, these findings suggest that changes in interstitial fluid dynamics, insulin resistance-induced impairment of muscle signaling, and disruption of liver–muscle crosstalk act in concert to link increased ECW/TBW with impaired SLST. The relationship between decreased SLST and elevated ECW/TBW demonstrated in this study is not a mere correlation, but rather reflects a comprehensive pathophysiological process involving fluid imbalance, disrupted metabolic signaling, and changes in muscle quality." (Discussion, Page 26, Lines 430–433): “Finally, the ECW/TBW cutoff value of 0.393 was derived from the present dataset, and external validation is needed prior to clinical application. Future prospective studies should aim to collect more detailed data on these variables to confirm and expand upon our findings.” - Ensure consistency in terminology (e.g., always use “diabetes mellitus (DM)” after first mention), abbreviation use, and statistical formatting (e.g., p-values). Response: Thank you for your helpful comment. We have revised the manuscript to ensure consistency in terminology. Specifically, we used the full term “diabetes mellitus (DM)” at its first appearance and used the abbreviation “DM” thereafter throughout the text. Additionally, we standardized the presentation of p-values to either “p = 0.xxx” or “p < 0.001” as appropriate. To the Journal requirements 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response: Thank you for your valuable comment. We have adjusted the manuscript formatting, including file naming, in accordance with the PLOS ONE style requirements. 2. Thank you for stating the following financial disclosure: “This work was supported by a grant (H30-A59) from the Japanese Society of Physical Therapy and Japan Society for the Promotion of Science KAKENHI Grant Number JP19K19831.” Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. Response: Thank you for your confirmation. We have included the following statement regarding the role of the funders in the cover letter: (Response letter, Page 1) "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." 3. In this instance it seems there may be acceptable restrictions in place that prevent the public sharing of your minimal data. However, in line with our goal of ensuring long-term data availability to all interested researchers, PLOS’ Data Policy states that authors cannot be the sole named individuals responsible for ensuring data access (http://journals.plos.org/plosone/s/data-availability#loc-acceptable-data-sharing-methods). Data requests to a non-author institutional point of contact, such as a data access or ethics committee, helps guarantee long term stability and availability of data. Providing interested researchers with a durable point of contact ensures data will be accessible even if an author changes email addresses, institutions, or becomes unavailable to answer requests. Before we proceed with your manuscript, please also provide non-author contact information (phone/email/hyperlink) for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If no institutional body is available to respond to requests for your minimal data, please consider if there any institutional representatives who did not collaborate in the study, and are not listed as authors on the manuscript, who would be able to hold the data and respond to external requests for data access? If so, please provide their contact information (i.e., email address). Please also provide details on how you will ensure persistent or long-term data storage and availability. Response: Thank you for your comment. We confirm that data access will not be solely managed by the authors. We have arranged with the Hiroshima University Library to archive the dataset in the Hiroshima University Institutional Repository (https://ir.lib.hiroshima-u.ac.jp), and they have agreed to act as the non-author institutional contact for data access inquiries. Please direct any inquiries regarding the dataset to: Hiroshima University Library Email: tosho-soumu@office.hiroshima-u.ac.jp Website: https://www.lib.hiroshima-u.ac.jp/ The library has committed to long-term preservation and public access to the dataset, ensuring that data remain available even if authors become unreachable. 4. When completing the data availability statement of the submission form, you indicated that you will make your data available on acceptance. We strongly recommend all authors decide on a data sharing plan before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. Response: We confirm that the minimal dataset will be deposited in the Hiroshima University Institutional Repository and made freely and publicly accessible upon acceptance of the manuscript. The Hiroshima University Library has already agreed to this and the registration process is underway. We will update the Data Availability Statement in the manuscript as follows: Data Availability: “All relevant data will be made available without restriction in the Hiroshima University Institutional Repository (https://ir.lib.hiroshima-u.ac.jp) following acceptance. Data requests may also be directed to Hiroshima University Library (tosho-soumu@office.hiroshima-u.ac.jp), which will manage long-term data access.” 5. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical. Response: Thank you for your valuable comment. We have standardized the manuscript title in both the online submission system and within the manuscript itself as follows: (Page 1, Lines 4–5) “Association between diabetes mellitus and impaired single-leg stance in patients with chronic liver disease: a cross-sectional study” To the Reviewer: 1 Introduction (Lines 48–72) - Line 67: Reference specific studies showing increased fall risk due to diabetic neuropathy or proprioceptive impairment. Response: Thank you very much for your valuable comment. In accordance with your suggestion, we have added several key references to support this point. The revised manuscript now states: (Introduction, Page 4, Lines 82–86): "Patients with DM also experience impaired balance due to factors such as peripheral neuropathy, hypoglycemia, and delayed reaction times [42-44]; the presence of DM alone increases the risk of falls [45]. Peripheral Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0345407.r002
23 Dec 2025 Decision Letter - Rafael Oliveira, Editor Dear Dr. Asaeda, 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 Feb 06 2026 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. A 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 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, Rafael Oliveira Academic Editor PLOS One Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 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. Additional Editor Comments: Dear authors, The authors improved their by following the comments made by reviewer in the first division. However, there are still margin for improvements. Therefore, another round of revisions will be requested. Please considerer the comments made by reviewers and see the following specific comments for more details: -in abstract, please add effect sizes when it's appropriate; -L60-63 require at least one more citation or please rewrite the sentence; -L87-91, please support your hypothesis with references; -in materials and methods section, the order of evaluations and rest between them should be described; -please add the type of the study; -L140, please describe the time of the day for the assessment and what were the conditions applied before the assessment; -L142, please add information about validity of the device; -L206, effect sizes should be calculated and added for the appropriate analysis; -Table 1, please check table format and size because it is too long (3 pages). In addition, please add units for all variables; -for tables 2 and 3, please add effect sizes and their interpretation Best regards [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #3: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #3: (No Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #3: Yes ****** Reviewer #3: Manuscript Title: Association between diabetes mellitus and impaired single-leg stance in patients with chronic liver disease: a cross-sectional study Journal: PLOS One Authors: Makoto Asaeda et al. Decision: Minor Revision Rationale: The manuscript addresses a clinically important question and presents novel findings regarding ECW/TBW. However, some concerns need to be thoroughly addressed before the manuscript can be considered for publication. Key Revisions Requested Abstract 1. Line 45: "Patients with DM had a significantly higher prevalence of impaired SLST than those without DM (20% vs 0%, p = 0.002)." A 0% rate in the non-DM group is striking. While statistically significant, it is worth noting that the non-DM group was small (n = 34), and this result may be sensitive to sample size. Introduction 1. Lines 87-91: The hypothesis and aim are clear. Well-stated. Methods 1. Timing of Assessments (Lines 95-103, 118-121): The protocol where blood tests (admission) and physical function assessments (start of physiotherapy) occurred at different, unspecified times is a significant flaw. Clinical status, especially fluid balance (ECW/TBW), can change rapidly, introducing substantial measurement bias and weakening the core cross-sectional associations. 2. Unmeasured Confounding - Diabetic Neuropathy (Throughout): The most critical limitation is the absence of any assessment or adjustment for diabetic peripheral neuropathy. As a primary mechanism for balance impairment in DM, neuropathy is a profound confounder. The observed association between DM and impaired SLST may be entirely mediated by neuropathy, drastically altering the interpretation of the results. 3. Sample Generalizability (Lines 232-236): The cohort, with a remarkably high DM prevalence (78%) and predominantly compensated liver disease (83% Child-Pugh A), is highly selective. This limits the generalizability of the findings to the broader CLD population and should be explicitly acknowledged as a limitation. Results 1. Lines 272-279: When presenting comparative results (e.g., KEF/weight, grip strength), ensure that the descriptive statistics (mean ± SD vs. median [IQR]) match the tests used (t-test vs. Mann-Whitney U) as reported in the tables. Discussion 1. Lines 368-371: The discussion about the null finding for ammonia is reasonable given the population's characteristics. 2. Lines 392-394, 441-443: The concept of "subclinical edema" is interesting and a useful clinical takeaway. This is well-argued. 3. Lines 395-419: The pathophysiological discussion is comprehensive but somewhat speculative, especially the detailed molecular mechanisms (IR/IGF-IR/FoxO, myostatin), given that the study did not measure any of these parameters. This section could be shortened and framed more as potential explanatory hypotheses for future research rather than established explanations for the current findings. Conclusion 1. The conclusions are generally supported by the data but should be tempered by acknowledging the key limitations, such as the cross-sectional design, lack of data on neuropathy, and the specific characteristics of the study cohort. ****** 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 #3: 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". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0345407.r003
Revision 2
4 Feb 2026 Author Response February 4, 2026 Dr. Bisher Sawaf Academic Editor PLOS ONE Dear Dr. Sawaf: Thank you for your consideration of our revised manuscript. We are grateful to the reviewers for their insightful and constructive feedback. We have addressed all the concerns raised by the editor and Reviewer #3. A point-by-point response is provided below. In this revised manuscript, we have addressed all the reviewers' concerns, specifically regarding the standardizing of body composition assessment protocols, the clarification of statistical effect sizes, and the refinement of the study’s limitations. All changes in the revised manuscript are highlighted in red font. Please ensure this correction is reflected in the author list and manuscript metadata upon acceptance. We greatly appreciate the opportunity to revise our work and look forward to your response. Best regards, Makoto Asaeda Department of Rehabilitation Medicine, Hiroshima University Hospital 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan TEL: +81-82-257-5566 E-mail: asaedam@hiroshima-u.ac.jp https://doi.org/10.1371/journal.pone.0345407.r004
8 Feb 2026 Decision Letter - Rafael Oliveira, Editor Dear Dr. <!--StartFragment-->Makoto Asaeda<!--EndFragment-->, 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. ============================== ACADEMIC EDITOR: The authors improved their work, but there is still an issue that avoid my recommendation of acceptance. Thus, I'll require another round of revisions. Specifically, please consider the following comments: -L146-148, "To ensure data consistency, all measurements were conducted during the daytime and at least 2 hours after the last meal." Can you support this methodological choice with references, since this is not a standard procedure for body composition analysis? Moreover, were some procedures regarding food and water intake before the assessment? -L220-221, for Cohen's D, R and V Cramer's, references to support the values of interpretations are needed. In addition, rather than specific values, authors should be present ranges for each interpretation, for better clarity; -L438-439, in theses sentences there are two "sixth" limitations. The second time should be replaced by "seventh". -96 references are too much for an original manuscript. This number should be reduced and not exceed 60. Best regards ============================== Please submit your revised manuscript by Mar 25 2026 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. A 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 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, Rafael Oliveira Academic Editor PLOS One Journal Requirements: If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 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. Additional Editor Comments (if provided): Dear authors, The authors improved their work, but there is still an issue that avoid my recommendation of acceptance. Thus, I'll require another round of revisions. Specifically, please consider the following comments: -L146-148, "To ensure data consistency, all measurements were conducted during the daytime and at least 2 hours after the last meal." Can you support this methodological choice with references, since this is not a standard procedure for body composition analysis? Moreover, were some procedures regarding food and water intake before the assessment? -L220-221, for Cohen's D, R and V Cramer's, references to support the values of interpretations are needed. In addition, rather than specific values, authors should be present ranges for each interpretation, for better clarity; -L438-439, in theses sentences there are two "sixth" limitations. The second time should be replaced by "seventh". -96 references are too much for an original manuscript. This number should be reduced and not exceed 60. Best regards [Note: HTML markup is below. Please do not edit.] [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". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. https://doi.org/10.1371/journal.pone.0345407.r005
Revision 3
1 Mar 2026 Author Response March 2, 2026 Dr. Rafael Oliveira Academic Editor PLOS ONE Dear Dr. Oliveira, Thank you for the further review of our manuscript, Manuscript ID: PONE-D-25-15349R2, Title: Association between diabetes mellitus and impaired single-leg stance in patients with chronic liver disease: a cross-sectional study. We appreciate your helpful comments, which have allowed us to refine our work even further. We have addressed all your suggestions in the revised manuscript. Our point-by-point responses are provided below. Best regards, Makoto Asaeda Department of Rehabilitation Medicine, Hiroshima University Hospital 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan TEL: +81-82-257-5566 E-mail: asaedam@hiroshima-u.ac.jp Attachments Attachment Submitted filename: Response_to_Reviewers.docx https://doi.org/10.1371/journal.pone.0345407.r006
5 Mar 2026 Decision Letter - Rafael Oliveira, Editor Association between diabetes mellitus and impaired single-leg stance in patients with chronic liver disease: a cross-sectional study PONE-D-25-15349R3 Dear Dr. Makoto Asaeda, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . 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, Rafael Oliveira Academic Editor PLOS One Additional Editor Comments (optional): Dear authors, Thank you by following all suggestions. The manuscript was improved. There is only one issue related with in text citations because when there is more more than one reference, they should be merged and the current version did not present them in that way. Still, the manuscript can be accepted and the issue be fixed during the proofreading stage. Congratulations! Best regards Reviewers' comments: https://doi.org/10.1371/journal.pone.0345407.r007

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