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Episode 40 focuses on lean NASH, and Michelle Long notes that many patients with lean NASH are diagnosed in the Emergency Department when they present with symptoms of decompensating cirrhosis. This conversation from November 2021 considers cirrhotic patients from a different perspective: their uniquely valuable role in clinical trial strategy as the world evolves beyond biopsy as gold standard.

Mazen Noureddin notes during this week's episode that when he identifies lean NASH patients, he encourages them strongly to participate in clinical trials. This conversation also looks at the value of cirrhosis studies in clinical trial design, although from a quite different perspective.

From the initial description of this conversation: In this conversation, Stephen Harrison starts by pointing out that non-cirrhotic NASH trials and NASH cirrhosis trials differ significantly in goals, endpoints and patient severity. From there, he dives into the NASH cirrhosis trial group with his review of REVERSE, which Vlad Ratziu presented at AASLD. Jörn Schattenberg and Mazen Noureddin also comment on design of this trial. The conversation focuses on two issues: who is the optimal patient for a NASH cirrhosis trial and what is the most appropriate attainable endpoint and, therefore, clinical design? On the optimal patient issue, the group agrees the ideal patient is a well-compensated cirrhotic, because the presence of portal hypertension makes the entire healing issue so much more complex. There was less agreement on the optimal design question.