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Commentary: Predictors of survival in autoimmune liver disease overlap syndromes Jian-Guo Zhang,Biao Wen Jian-Guo Zhang,Biao Wen,Department of Gastroenterology, The First Affiliated Hospital of Chengdu Medical College, Chengdu 610000, Sichuan Province, China Author contributions:Jian-Guo Zhang wrote the original draft; Biao Wen contributed to conceptualization, writing, reviewing and editing; Jian-Guo Zhang and Biao Wen participated in drafting the manuscript; and all authors have read and approved the final version of the manuscript. ORCID number：0000-0001-5226-5981 Corresponding author:Biao Wen,MD, PhD,Assistant Professor,Department of Gastroenterology, The First Affiliated Hospital of Chengdu Medical College,No. 312, Middle Section of Baoguang Avenue, Xindu District, Chengdu 610000, Sichuan Province, China. 820695761@qq.com We perused the article authored by Jayabalan et al[1]with considerable interest and extend our congratulations to the authors for their commendable endeavor. The authors have reported a prospective investigation into the predictors of survival in patients with autoimmune liver disease overlap syndromes (AILDOS)[1]. The study's conclusion suggests that the LOS holds potential as a predictive tool for liver-related mortality in individuals with autoimmune hepatitis and primary biliary cholangitis overlap (AIH-PBC)[1]. However, several aspects of this study merit further scrutiny and discussion. Firstly, a critical exclusion criterion for the study was the prior performance of a liver transplant prior to enrollment[1]. Upon consideration, we postulated the possibility that a portion of the enrolled patients might harbor coexisting liver pathology stemming from disparate causes (including, but not limited to, alcoholic liver disease or viral hepatitis), which could introduce bias and complicate the interpretation of our results. Therefore, we advised the authors to implement rigorous exclusion criteria for such patients to uphold the accuracy and reliability of our findings. Secondly, the diagnoses of autoimmune hepatitis (AIH), primary biliary cirrhosis (PBC), and primary sclerosing cholangitis (PSC) were established in accordance with the criteria stipulated by the International Autoimmune Hepatitis Group, the European Association for the Study of the Liver Clinical Practice Guidelines, and the American College of Gastroenterology Clinical Guidelines, respectively[1-4]. It is noteworthy that these diagnostic criteria originate from disparate geographical regions, and the progression of research concerning each disease varies across these regions. Consequently, such variability may potentially impact the precision of the study's findings. In light of this, we propose that the authors consider adopting diagnostic criteria from a uniform geographical region. Therefore, we recommend the uniform application of diagnostic guidelines or consensus recommendations established by reputable institutions in the United States for the purposes of disease ascertainment. Such standardization is poised to substantially elevate the reliability and validity of the research findings, thereby reinforcing the scientific rigor and credibility of the conducted studies.[4-6]. Thirdly, the authors confined their analysis solely to the occurrence or absence of liver-related mortality, while neglecting to account for the medical interventions undergone by the patients during the follow-up period[1]. It is imperative to elucidate the potential impact of these interventions on the study's findings. A comprehensive assessment of the medical interventions received by the patients is crucial for ensuring the accuracy and robustness of the study's conclusions. Ultimately, as highlighted by the authors, the primary limitation of this study is the relatively modest sample size[1]. Consequently, it is imperative that future research endeavors incorporate larger sample populations and adopt a multicenter design to validate the findings of the present study and further elucidate the pertinence to patients with AIH-PSC. Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported. REFERENCES 1 Jayabalan D, Huang Y, Calzadilla-Bertot L, Janjua M, de Boer B, Joseph J, Cheng W, Hazeldine S, Smith BW, MacQuillan GC, Wallace MC, Garas G, Adams LA, Jeffrey GP. Predictors of survival in autoimmune liver disease overlap syndromes. World J Hepatol 2024; 16: 1269-1277. [PMID:39351512 DOI: 10.4254/wjh.v16.i9.1269] 2 European Association for the Study of the Liver. EASL Clinical Practice Guidelines: The diagnosis and management of patients with primary biliary cholangitis. J Hepatol 2017; 67: 145-172. [PMID: 28427765 DOI: 10.1016/j.jhep.2017.03.022] 3 Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis: Current Status and Future Directions. Gut Liver 2016; 10: 177-203. [PMID:26934884 DOI: 10.5009/gnl15352] 4 Lindor KD, Kowdley KV, Harrison ME. ACG Clinical Guideline: Primary Sclerosing Cholangitis. Am J Gastroenterol 2015; 110: 646-659, 660. [PMID: 25869391 DOI: 10.1038/ajg.2015.112] 5 Mack CL, Adams D, Assis DN, Kerkar N, Manns MP, Mayo MJ, Vierling JM, Alsawas M, Murad MH, Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases. Hepatology 2020; 72: 671-722. [PMID: 31863477 DOI: 10.1002/hep.31065] 6 Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M. Primary Biliary Cholangitis: 2018 Practice Guidance from the American Association for the Study of Liver Diseases. Hepatology 2019; 69: 394-419. [PMID:30070375 DOI: 10.1002/hep.30145]

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