DNA mismatch repair deficiency and hereditary syndromes in Latino patients with colorectal cancer.

BACKGROUND: The landscape of hereditary syndromes and clinicopathologic characteristics among US Latino/Hispanic individuals with colorectal cancer (CRC) remains poorly understood. METHODS: A total of 265 patients with CRC who were enrolled in the Hispanic Colorectal Cancer Study were included in the current study. Information regarding CRC risk factors was elicited through interviews, and treatment and survival data were abstracted from clinical charts. Tumor studies and germline genetic testing results were collected from medical records or performed using standard molecular methods. RESULTS: The mean age of the patients at the time of diagnosis was 53.7 years (standard deviation, 10.3 years), and 48.3% were female. Overall, 21.2% of patients reported a first-degree or second-degree relative with CRC; 3.4% met Amsterdam I/II criteria. With respect to Bethesda guidelines, 38.5% of patients met at least 1 criterion. Of the 161 individuals who had immunohistochemistry and/or microsatellite instability testing performed, 21 (13.0%) had mismatch repair (MMR)-deficient (dMMR) tumors. dMMR tumors were associated with female sex (61.9%), earlier age at the time of diagnosis (50.4 ± 12.4 years), proximal location (61.9%), and first-degree (23.8%) or second-degree (9.5%) family history of CRC. Among individuals with dMMR tumors, 13 (61.9%) had a germline MMR mutation (MutL homolog 1 [MLH1] in 6 patients; MutS homolog 2 [MSH2] in 4 patients; MutS homolog 6 [MHS6] in 2 patients; and PMS1 homolog 2, mismatch repair system component [PMS2] in 1 patient). The authors identified 2 additional MLH1 mutation carriers by genetic testing who had not received immunohistochemistry/microsatellite instability testing. In total, 5.7% of the entire cohort were confirmed to have Lynch syndrome. In addition, 6 individuals (2.3%) had a polyposis phenotype. CONCLUSIONS: The percentage of dMMR tumors noted among Latino individuals (13%) is similar to estimates in non-Hispanic white individuals. In the current study, the majority of individuals with dMMR tumors were confirmed to have Lynch syndrome. Cancer 2017. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. Cancer 2017;123:3732-3743. © 2017 American Cancer Society.

Curing Chronic Hepatitis C: A Cost Comparison of the Combination Simeprevir Plus Sofosbuvir vs. Protease-Inhibitor-Based Triple Therapy.

INTRODUCTION: Interferon-free, multi-direct acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection is highly effective and well tolerated, but costly. To gain perspective on the evolving economics of HCV therapy, we compared the cost per cure of a multi-DAA regimen with the prior standard of triple therapy. MATERIAL AND METHODS: Patients infected with HCV genotype 1 who were treated through the University of Colorado Hepatology Clinic between May 2011 and December 2014 comprised the study population. The multi-DAA regimen of simeprevir plus sofosbuvir (SMV/SOF) was compared to the triple therapy regimen consisting of peginterferon and ribavirin, with either boceprevir or telaprevir (TT). Sustained-virologic response (SVR) rates, total costs per treatment and adverse events were recorded. Total cost per SVR were compared for the two treatments, controlling for patient demographics and clinical characteristics. RESULTS: One hundred eighty-three patients received SMV/SOF (n = 70) or TT (n = 113). Patients receiving SMV/SOF were older, more treatment experienced, and had a higher stage of fibrosis. SVRs were 86% and 59%, average total costs per patient were $152,775 and $95,943, and average total costs per SVR were $178,237 vs. $161,813.49 for SMV/SOF and TT groups, respectively. Medication costs accounted for 98% of SMV/SOF and 85% of TT treatment costs. CONCLUSION: The high cure rate of multi-DAA treatment of HCV is offset by the high costs of the DAAs, such that the cost per cure from TT to multi-DAA therapy has been relatively constant. In order to cure more patients, either additional financial resources will need to be allocated to the treatment of HCV or drug costs will need to be reduced.

Interleukin-2 receptor antagonist therapy leads to increased tacrolimus levels after kidney transplantation.

BACKGROUND: Tacrolimus (TAC) is a known substrate for cytochrome P450 (CYP) enzyme. CYP enzyme activity can be modulated by activation of IL-2 receptors (IL-2R) expressed on hepatocytes and intestinal cells. IL-2R antagonists (IL-2RA) may promote preferential binding of circulating IL-2 to IL-2Rs on these cells by blocking IL-2Rs on activated T cells. This downregulates CYP enzymes, leading to increased calcineurin inhibitor levels. This analysis evaluates the significance of this drug-drug interaction in kidney transplant recipients. METHODS: Data were used from a previous 5-year randomized, controlled study comparing outcomes associated with maintenance immunosuppression using 2 corticosteroid regimens: long-term therapy versus early withdrawal. Patients received either IL-2RAs or rabbit anti-thymocyte globulin (rATG) for induction. Serial TAC trough levels and doses were compared between induction agents within each corticosteroid arm. Rejection rates, patient/graft survival, and TAC adverse effects were also evaluated. RESULTS: In the first week, IL-2RA-treated patients achieved significantly higher trough levels and required lower doses (in milligram per kilogram) to achieve target levels than rATG-treated patients. No significant differences in rejection rates, patient/graft survival, or rate of adverse effects were observed through 1 year.

Peripheral MC1R activation modulates immune responses and is neuroprotective in a mouse model of Parkinson's disease.

Background: Melanocortin 1 receptor (MC1R) is a key pigmentation gene, and loss-of-function of MC1R variants that produce red hair may be associated with Parkinson's disease (PD). We previously reported compromised dopaminergic neuron survival in Mc1r mutant mice and dopaminergic neuroprotective effects of local injection of a MC1R agonist to the brain or a systemically administered MC1R agonist with appreciable CNS permeability. Beyond melanocytes and dopaminergic neurons, MC1R is expressed in other peripheral tissues and cell types, including immune cells. The present study investigates the impact of NDP-MSH, a synthetic melanocortin receptor (MCR) agonist that does not cross BBB, on the immune system and the nigrostriatal dopaminergic system in mouse model of PD. Methods: C57BL/6 mice were treated systemically with MPTP.HCl (20 mg/kg) and LPS (1 mg/kg) from day 1 to day 4 and NDP-MSH (400 µg/kg) or vehicle from day 1 to day 12 following which the mice were sacrificed. Peripheral and CNS immune cells were phenotyped and inflammatory markers were measured. The nigrostriatal dopaminergic system was assessed behaviorally, chemically, immunologically, and pathologically. To understand the role of regulatory T cells (Tregs) in this model, CD25 monoclonal antibody was used to deplete CD25+ Tregs. Results: Systemic NDP-MSH administration significantly attenuated striatal dopamine depletion and nigral dopaminergic neuron loss induced by MPTP+LPS. It improved the behavioral outcomes in the pole test. Mc1r mutant mice injected with NDP-MSH in the MPTP and LPS paradigm showed no changes in striatal dopamine levels suggesting that the NDP-MSH acts through the MC1R pathway. Although no NDP-MSH was detected in the brain, peripheral, NDP-MSH attenuated neuroinflammation as observed by diminished microglial activation in the nigral region, along with reduced TNF-α and IL1ß levels in the ventral midbrain. Depletion of Tregs limited the neuroprotective effects of NDP-MSH. Conclusions: Our study demonstrates that peripherally acting NDP-MSH confers protection on dopaminergic nigrostriatal neurons and reduces hyperactivated microglia. NDP-MSH modulates peripheral immune responses, and Tregs may be involved in the neuroprotective effect of NDP-MSH.

Microglia-dependent neuroprotective effects of 4-octyl itaconate against rotenone-and MPP+-induced neurotoxicity in Parkinson's disease.

Chronic neuroinflammation is implicated in the pathogenesis of Parkinson's disease (PD), one of the most common neurodegenerative diseases. Itaconate, an endogenous metabolite derived from the tricarboxylic acid cycle via immune-responsive gene 1 activity, may mediate anti-inflammatory responses by activation of the nuclear factor erythroid 2-related factor 2 (Nrf2) antioxidant pathway. This study investigates the neuroprotective potential of 4-octyl itaconate (OI), a cell-permeable derivative of itaconate, in cellular models of PD. OI not only suppressed lipopolysaccharide-induced proinflammatory cascades of inducible nitric oxide synthase, cyclooxygenase-2, and cytokines release in mouse BV2 microglial cells but also activated the Nrf2 signaling pathway and its downstream targets in these cells. Conditioned medium derived from OI-treated BV2 cells protected against rotenone- and MPP+-induced neurotoxicity in Neuro 2A cells. Overall, our findings support the anti-inflammatory neuroprotective potential of OI in PD.

Peripheral MC1R Activation Modulates Immune Responses and is Neuroprotective in a Mouse Model of Parkinson's Disease.

BACKGROUND: Melanocortin 1 receptor (MC1R) is a key pigmentation gene, and loss-of-function of MC1R variants that produce red hair may be associated with Parkinson's disease (PD). We previously reported compromised dopaminergic neuron survival in Mc1r mutant mice and dopaminergic neuroprotective effects of local injection of a MC1R agonist to the brain or a systemically administered MC1R agonist with appreciable central nervous system (CNS) permeability. Beyond melanocytes and dopaminergic neurons, MC1R is expressed in other peripheral tissues and cell types, including immune cells. The present study investigates the impact of NDP-MSH, a synthetic melanocortin receptor (MCR) agonist that does not cross BBB, on the immune system and the nigrostriatal dopaminergic system in mouse model of PD. METHODS: C57BL/6 mice were treated systemically with MPTP.HCl (20 mg/kg) and LPS (1 mg/kg) from day 1 to day 4 and NDP-MSH (400 µg/kg) or vehicle from day 1 to day 12 following which the mice were sacrificed. Peripheral and CNS immune cells were phenotyped and inflammatory markers were measured. The nigrostriatal dopaminergic system was assessed behaviorally, chemically, immunologically, and pathologically. To understand the role of regulatory T cells (Tregs) in this model, CD25 monoclonal antibody was used to deplete CD25 + Tregs. RESULTS: Systemic NDP-MSH administration significantly attenuated striatal dopamine depletion and nigral dopaminergic neuron loss induced by MPTP + LPS. It improved the behavioral outcomes in the pole test. Mc1r mutant mice injected with NDP-MSH in the MPTP and LPS paradigm showed no changes in striatal dopamine levels suggesting that the NDP-MSH acts through the MC1R pathway. Although no NDP-MSH was detected in the brain, peripheral, NDP-MSH attenuated neuroinflammation as observed by diminished microglial activation in the nigral region, along with reduced TNF-α and IL1ß levels in the ventral midbrain. Depletion of Tregs was associated with diminished neuroprotective effects of NDP-MSH. CONCLUSIONS: Our study demonstrates that peripherally acting NDP-MSH confers protection on dopaminergic nigrostriatal neurons and reduces hyperactivated microglia. NDP-MSH modulates peripheral immune responses, and Tregs may be involved in the neuroprotective effect of NDP-MSH.

Impact of COVID-19 infection among cancer patients treated at the Los Angeles County Medical Center.

We conducted a retrospective analysis of cancer patients who presented to the hospital with COVID-19 infection at a safety-net hospital in Los Angeles, California, from March 2020 to June 2020. From a list of 1,163 COVID-19+ adult patients, we selected the first 50 patients with malignancy for a preliminary analysis. There were 23 males (46.0%) and 27 females (54.0%); the median age was 60.5 years (IQR 47 - 72). Thirty-nine (78.0%) of the patients were Hispanic. The most prevalent cancers were genitourinary (14, 28.0%), hematologic (11, 22.0%), and gastrointestinal (10, 20.0%). Twenty-one (42.0%) patients had active disease at COVID-19 diagnosis, while 25 (50.0%) had no evidence of disease (NED), and 4 (8.0%) were unknown. Over 1 in 3 admitted patients experienced a "severe outcome," which was defined as critical level care (14, 34.1%), use of vasopressors (9, 22.0%), intubation (8, 19.5%), or death (5, 12.2%). Patients with severe outcomes were found to have statistically higher values of absolute neutrophil count (p = 0.005), aspartate aminotransferase (p = 0.049), high-sensitivity C-reactive protein, (p = 0.001) and lactate dehydrogenase (p = 0.040) on admission. Overall survival (OS) was not statistically different between those with hematologic versus solid malignancy nor between those with active disease versus remission (both p>0.05). Thirteen (81.3%) of the 16 patients who had cancer treatment in 2020 experienced delays in cancer therapy. Additional cases are being evaluated as the pandemic continues with the goal of identifying areas for potential intervention to improve outcomes in this at-risk population.

Gene regulatory networks controlling differentiation, survival, and diversification of hypothalamic Lhx6-expressing GABAergic neurons.

GABAergic neurons of the hypothalamus regulate many innate behaviors, but little is known about the mechanisms that control their development. We previously identified hypothalamic neurons that express the LIM homeodomain transcription factor Lhx6, a master regulator of cortical interneuron development, as sleep-promoting. In contrast to telencephalic interneurons, hypothalamic Lhx6 neurons do not undergo long-distance tangential migration and do not express cortical interneuronal markers such as Pvalb. Here, we show that Lhx6 is necessary for the survival of hypothalamic neurons. Dlx1/2, Nkx2-2, and Nkx2-1 are each required for specification of spatially distinct subsets of hypothalamic Lhx6 neurons, and that Nkx2-2+/Lhx6+ neurons of the zona incerta are responsive to sleep pressure. We further identify multiple neuropeptides that are enriched in spatially segregated subsets of hypothalamic Lhx6 neurons, and that are distinct from those seen in cortical neurons. These findings identify common and divergent molecular mechanisms by which Lhx6 controls the development of GABAergic neurons in the hypothalamus.

The cellular and molecular landscape of hypothalamic patterning and differentiation from embryonic to late postnatal development.

The hypothalamus is a central regulator of many innate behaviors essential for survival, but the molecular mechanisms controlling hypothalamic patterning and cell fate specification are poorly understood. To identify genes that control hypothalamic development, we have used single-cell RNA sequencing (scRNA-Seq) to profile mouse hypothalamic gene expression across 12 developmental time points between embryonic day 10 and postnatal day 45. This identified genes that delineated clear developmental trajectories for all major hypothalamic cell types, and readily distinguished major regional subdivisions of the developing hypothalamus. By using our developmental dataset, we were able to rapidly annotate previously unidentified clusters from existing scRNA-Seq datasets collected during development and to identify the developmental origins of major neuronal populations of the ventromedial hypothalamus. We further show that our approach can rapidly and comprehensively characterize mutants that have altered hypothalamic patterning, identifying Nkx2.1 as a negative regulator of prethalamic identity. These data serve as a resource for further studies of hypothalamic development, physiology, and dysfunction.

Systemic lupus erythematosus presenting as Evans syndrome.

Hematologic abnormalities are an important part of the diagnostic criteria for systemic lupus erythematosus (SLE). This case presents a patient diagnosed with Evans Syndrome with underlying SLE on initial presentation.

Medication noncompliance and its implications in transplant recipients.

The transplant patient's therapeutic regimen consists of a lifelong drug therapy, including immunosuppressive drugs, prophylactic antimicrobials and often medications for the treatment of hypertension, diabetes mellitus and other comorbid diseases. Regular clinic appointments are required to monitor for signs and symptoms of immunological injury, recurrent disease and adverse drug effects. Patients are instructed to avoid risk factors for cardiovascular disease and cancer (e.g. diet, exercise, sun protection and not smoking). Noncompliance with all aspects of this regimen is substantial. Medication noncompliance leads to an increased incidence of acute rejection, chronic rejection and graft loss. Undoubtedly, many practitioners fail to appreciate the extent of noncompliance as the signs are often subtle and most patients are unwilling to disclose deliberate or widespread disregard for medication use. Newer immunosuppressive agents, particularly once-daily medications and long-acting antibody preparations offer convenience and monitoring that may improve compliance. This review focuses on the prevalence, correlates and consequences of medication nonadherence after organ transplantation. Current recommendations to enhance adherence are discussed.

Development of metastatic brain disease involves progression through lung metastases in EGFR mutated non-small cell lung cancer.

Lung cancer is often classified by the presence of oncogenic drivers, such as epidermal growth factor receptor (EGFR), rather than patterns of anatomical distribution. While metastatic spread may seem a random and unpredictable process, we explored the possibility of using its quantifiable nature as a measure of describing and comparing different subsets of disease. We constructed a database of 664 non-small cell lung cancer (NSCLC) patients treated at the University of Southern California Norris Comprehensive Cancer Center and the Los Angeles County Medical Center. Markov mathematical modeling was employed to assess metastatic sites in a spatiotemporal manner through every time point in progression of disease. Our findings identified a preferential pattern of primary lung disease progressing through lung metastases to the brain amongst EGFR mutated (EGFR m) NSCLC patients, with exon 19 deletions or exon 21 L858R mutations, as compared to EGFR wild type (EGFR wt). The brain was classified as an anatomic "sponge", with a higher ratio of incoming to outgoing spread, for EGFR m NSCLC. Bone metastases were more commonly identified in EGFR wt patients. Our study supports a link between the anatomical and molecular characterization of lung metastatic cancer. Improved understanding of the differential biology that drives discordant patterns of anatomic spread, based on genotype specific profiling, has the potential to improve personalized oncologic care.

Perioperative management of immunosuppression.

Current immunosuppressive regimens typically consist of two phases: induction phase (medications given at the time of the initial transplant) and maintenance therapy. Induction medications are given to decrease the occurrence of early acute rejection, avoid or minimise corticosteroids, and potentially induce long-term favourable immunoregulatory effects. As tolerance remains an elusive goal, life-long maintenance immunosuppression is required after all solid-organ transplantations. The various agents used in these two phases of immunosuppression are reviewed in this article. The similarities and differences between the agents within each class, with respect to efficacy and tolerability, are discussed.

Improved overall survival and mortality in head and neck cancer with adjuvant concurrent chemoradiotherapy in national databases.

BACKGROUND: Many studies have demonstrated the advantage of postoperative concurrent chemoradiotherapy (CRT) over radiotherapy (RT) alone in locoregional control, but few have examined overall survival with respect to national databases. METHODS: The literature was searched for eligible randomized controlled trials. The Surveillance, Epidemiology, and End Results (SEER) Database and National Cancer Data Base (NCDB) were searched for 5-year overall survival data. RESULTS: Twenty-eight studies were examined and demonstrated 44% greater locoregional control (relative risk [RR] = 0.56; 95% confidence interval [CI] = 0.46-0.68) and 12% overall survival benefit (RR = 0.88; 95% CI = 0.81-0.98) with postoperative adjuvant CRT compared to adjuvant RT. Overall SEER survival was 45.0% in 1973, rising to 53.2% in 2005. The NCDB documents a similar increase in overall survival from 45.5% in 1994 to 53.4% in 2005. CONCLUSION: The literature shows mortality benefit of adjuvant CRT in patients with advanced head and neck cancer, reflected in SEER and NCDB.

Metastatic Colorectal Cancer in Hispanics: Treatment Outcomes in a Treated Population.

BACKGROUND: In United States Hispanics have disparities in the presentation and outcome of colorectal cancer (CRC) largely attributed to their late presentation and lower socioeconomic status. Impact of treatment, especially in the metastatic setting, in the observed outcome is an unexplored area. We explored the role of treatment in the outcome of metastatic CRC we performed a retrospective analysis to assess the contribution of demographics, tumor characteristics, and health care setting on survival differences. PATIENTS AND METHODS: We conducted a retrospective study of patients who were treated with metastatic CRC at Los Angeles County Hospital-University of Southern California (LAC-USC, a public hospital) and Norris Comprehensive Cancer Center (NCCC, private hospital) between 2002 and 2012. Both these institutions are staffed by the same providers and therefore treatment algorithms and access to drugs were similar. We identified metastatic CRC patients who received chemotherapy from administrative records. Demographics, tumor, and treatment related factors were collected. The primary end point was time to progression (TTP: time from the first day of chemotherapy to the date of progression). Overall survival (OS) was measured from the first day of chemotherapy to death or last follow-up. Descriptive statistics were used to describe the population and chi-square, Wilcoxon, and log-rank tests were used for comparison between the groups. RESULTS: A total of 242 patients, 44% Hispanic, 26% non-Hispanic whites (NHWs), 21% Asian and 9% black were included. Median TTP was 9.2 months (95% confidence interval [CI], 7.6-11.6) in Hispanics, and 20.7 months (95% CI, 9.6-27.5; P < .05) in NHWs. Median OS in Hispanics was 16.3 months (95% CI, 13.3-18.5), and in NHWs was 33.5 months (95% CI, 22.1-63.6; P < .001). Hispanics who were treated at LAC-USC had longer TTP in comparison to Hispanics at NCCC (P = .04). CONCLUSION: Hispanics with metastatic CRC have shorter TTP and OS on first line therapy when adjusted for health care setting, demographics, disease characteristics, and treatment factors.

Declines in swimming performance with age: a longitudinal study of Masters swimming champions.

INTRODUCTION: Because of its many participants and thorough records, competitive Masters swimming offers a rich data source for determining the rate of physical decline associated with aging in physically fit individuals. The decline in performance among national champion swimmers, both men and women and in short and long swims, is linear, at about 0.6% per year up to age 70-75, after which it accelerates in quadratic fashion. These conclusions are based primarily on cross-sectional studies, and little is known about individual performance declines with aging. Herein we present performance profiles of 19 male and 26 female national and international champion Masters swimmers, ages 25 to 96 years, participating in competitions for an average of 23 years. METHODS AND RESULTS: Swimmers' longitudinal data were compared with the fastest times of world record holders across ages 35-100 years by two regression methods. Neither method proved to accurately model this data set: compared with the rates of decline estimated from the world record data, which represent the best recorded times at given ages, there was bias toward shallower rates of performance decline in the longitudinal data, likely owing to a practice effect in some swimmers as they began their Masters programs. In swimmers' later years, once maximum performance had been achieved, individual profiles followed the decline represented in the world records, and a few swimmers became the world record holders. In some instances, the individual profiles indicated performance better than the world record data; these swimmers achieved their times after the world record data were collected in 2005-2006. CONCLUSION: Declining physiological functional capacity occurs with advancing age, and this is reflected in the performance decrements of aging Masters swimmers. Individual swimmers show different performance trajectories with aging, declines being mitigated by practice, which improves both physiological capacity and swimming technique, particularly in the early years of participation. The longitudinal data of this study indicate that individuals can participate in high-intensity swimming over several decades, competitively improving over those decades until, in some instances, they become world record holders for their age groups.

Curing Chronic Hepatitis C: A Cost Comparison of the Combination Simeprevir Plus Sofosbuvir vs. Protease-Inhibitor-Based Triple Therapy

ABSTRACT Introduction. Interferon-free, multi-direct acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) infection is highly effective and well tolerated, but costly. To gain perspective on the evolving economics of HCV therapy, we compared the cost per cure of a multi-DAA regimen with the prior standard of triple therapy. Material and methods. Patients infected with HCV genotype 1 who were treated through the University of Colorado Hepatology Clinic between May 2011 and December 2014 comprised the study population. The multi-DAA regimen of simeprevir plus sofosbuvir (SMV/SOF) was compared to the triple therapy regimen consisting of peginterferon and ribavirin, with either boceprevir or telaprevir (TT). Sustained-virologic response (SVR) rates, total costs per treatment and adverse events were recorded. Total cost per SVR were compared for the two treatments, controlling for patient demographics and clinical characteristics. Results. One hundred eighty-three patients received SMV/SOF (n = 70) or TT (n = 113). Patients receiving SMV/SOF were older, more treatment experienced, and had a higher stage of fibrosis. SVRs were 86% and 59%, average total costs per patient were $152,775 and $95,943, and average total costs per SVR were $178,237 vs. $161,813.49 for SMV/SOF and TT groups, respectively. Medication costs accounted for 98% of SMV/SOF and 85% of TT treatment costs. Conclusion. The high cure rate of multi-DAA treatment of HCV is offset by the high costs of the DAAs, such that the cost per cure from TT to multi-DAA therapy has been relatively constant. In order to cure more patients, either additional financial resources will need to be allocated to the treatment of HCV or drug costs will need to be reduced.

Drug dosing considerations for the critically ill patient with liver disease.

Hepatic dysfunction in the critically ill patient presents a unique challenge to clinicians when designing pharmacotherapeutic treatment plans. Overall, the literature regarding drug dosing in critically ill patients with hepatic dysfunction is incomplete and current tools available to bedside clinicians have limitations. Despite these challenges, rational drug regimens can be implemented by critical care nurses who consider the potential impact of hepatic dysfunction on drug pharmacokinetics. This information can be applied clinically and careful monitoring plans can be implemented to assess a drug for efficacy and safety. This article reviews the pharmacokinetic changes that can occur in hepatic failure, identifies practical ways to quantify the severity of dysfunction, and discusses general drug dosing strategies in this patient population.