Letter to the Editor: Beyond the liver - integrating emerging predictors in hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

Core Tip

Core Tip: While Zhuang et al identify cerebral hypoperfusion as a hallmark of post-transjugular intrahepatic portosystemic shunt encephalopathy, this letter argues that these changes represent the final downstream consequence of a systemic multi-hit failure. We integrate emerging evidence on the gut-liver-muscle axis, emphasizing that sarcopenia, the AMMON-OHE model, and shunt magnitude are critical upstream determinants of neurotoxicity. We propose that to prevent cognitive decline, specialists must move beyond isolated hemodynamic targets and adopt a precision medicine approach, tailoring stent expansion to the patient's individual metabolic and muscular reserve.