In a related editorial, the author further discusses the question about whether pioglitazone alters clinical outcomes, such as development of ascites or encephalopathy, need for liver transplantation, or liver-related death? The author comments that “this meta-analysis identified significant improvements in histological features of the liver in patients treated with pioglitazone, but it did not look at clinical outcomes. Although liver histological status is a commonly used surrogate outcome in evaluating the efficacy of treatments for other hepatic conditions, it might not correlate as well with clinical outcomes in patients with nonalcoholic steatohepatitis (NASH), who are often obese and have type 2 diabetes and other complications of metabolic syndrome. Such patients are at high risk for serious cardiovascular and neurovascular complications (eg, myocardial infarction or stroke), which could influence clinical outcome more strongly than the complications of NASH.”