Red cell transfusion practices and the impact of phlebotomy in an adult intensive care unit in Trinidad--a prospective observational study

OBJECTIVES

To determine the pattern of current red cell transfusion practices in an adult intensive care unit (ICU) in Trinidad and the impact of phlebotomy on transfusions.

METHODS

A prospective observational study was conducted over a six-month period to include all patients who received transfusions in the ICU of Port-of-Spain General Hospital, Trinidad. Demographic data including age, gender and weight were recorded. Clinical data recorded were the admission APACHE II scores, daily phlebotomy volumes, haemoglobin levels, transfusions and outcome during the first thirty days following ICU admission. Patients were grouped according to diagnoses and transfusion patterns.

RESULTS

Of 134 patients admitted, 40 (29.8%) were transfused packed red cells 18 (29%) of the requests were for single unit transfusion. The mean phlebotomy volume was 13.5 +/- 4.3 (SD) mL day. The adjusted phlebotomy volume to body weight did not correlate with the amount of transfusions. The mean haemoglobin level for triggering blood transfusion was 6.73 g dL. The mean transfusion rate was 2.9 +/- 1.8 (SD) units per patient. Ten per cent of the patients received more than 5 units. Twenty nine per cent of the units were transfused on the first day of ICU admission and 69% were transfused during the first week of LCU stay.

CONCLUSIONS

Transfusion practices in the study ICU pointed towards a restrictive strategy, although there were some inappropriate transfusions. The phlebotomy volumes did not contribute towards transfusion requirements.

Calcineurin-inhibitor-free immunosuppression based on the JAK inhibitor CP-690,550: a pilot study in de novo kidney allograft recipients

This randomized, pilot study compared the Janus kinase inhibitor CP-690,550 (15 mg BID [CP15] and 30 mg BID [CP30], n = 20 each) with tacrolimus (n = 21) in de novo kidney allograft recipients. Patients received an IL-2 receptor antagonist, concomitant mycophenolate mofetil (MMF) and corticosteroids. CP-690,550 doses were reduced after 6 months. Due to a high incidence of BK virus nephropathy (BKN) in CP30, MMF was discontinued in this group. The 6-month biopsy-proven acute rejection rates were 1 of 20, 4 of 20 and 1 of 21 for CP15, CP30 and tacrolimus groups, respectively. BKN developed in 4 of 20 patients in CP30 group. The 6-month rates of cytomegalovirus disease were 2 of 20, 4 of 20 and none of 21 for CP15, CP30 and tacrolimus groups, respectively. Estimated glomerular filtration rate was >70 mL/min at 6 and 12 months (all groups). NK cells were reduced by </=77% in CP-690,550-treated patients. In the CP-690,550 arms, there were modest lipid elevations and a trend toward more frequent anemia and neutropenia during the first 6 months. These data suggest that coadministration of CP-690,550 30 mg BID with MMF is associated with overimmunosuppression. At 15 mg BID, the efficacy/safety profile was comparable to the tacrolimus control group, excepting a higher rate of viral infection. Further dose-ranging evaluation of CP-690,550 is warranted.

Calcineurin-inhibitor-free immunosuppression based on the JAK inhibitor CP-690,550: a pilot study in de novo kidney allograft recipients

This randomized, pilot study compared the Janus kinase inhibitor CP-690,550 (15 mg BID [CP15] and 30 mg BID [CP30], n = 20 each) with tacrolimus (n = 21) in de novo kidney allograft recipients. Patients received an IL-2 receptor antagonist, concomitant mycophenolate mofetil (MMF) and corticosteroids. CP-690,550 doses were reduced after 6 months. Due to a high incidence of BK virus nephropathy (BKN) in CP30, MMF was discontinued in this group. The 6-month biopsy-proven acute rejection rates were 1 of 20, 4 of 20 and 1 of 21 for CP15, CP30 and tacrolimus groups, respectively. BKN developed in 4 of 20 patients in CP30 group. The 6-month rates of cytomegalovirus disease were 2 of 20, 4 of 20 and none of 21 for CP15, CP30 and tacrolimus groups, respectively. Estimated glomerular filtration rate was >70 mL/min at 6 and 12 months (all groups). NK cells were reduced by </=77% in CP-690,550-treated patients. In the CP-690,550 arms, there were modest lipid elevations and a trend toward more frequent anemia and neutropenia during the first 6 months. These data suggest that coadministration of CP-690,550 30 mg BID with MMF is associated with overimmunosuppression. At 15 mg BID, the efficacy/safety profile was comparable to the tacrolimus control group, excepting a higher rate of viral infection. Further dose-ranging evaluation of CP-690,550 is warranted.

Economic evaluation of sunitinib versus other new targeted therapies as first-line treatment of metastatic renal cell carcinoma (mRCC) in the United States

e17556

Background: RCC, the most prevalent kidney cancer, is a relatively rare malignancy that carries a poor prognosis. New targeted therapies, such as sunitinib, sorafenib, temsirolimus, and bevacizumab + interferon-alfa (IFN-α), are now available in the US for the treatment of mRCC. In the absence of head-to-head trials, the aim of this analysis was to assess the economic value of these therapies as first-line treatment of mRCC from a U.S. third-party payer perspective, using an indirect comparison based on reported survival data. Methods: An economic model was built to simulate progression-free and overall survival based on each treatment's hazard ratio against IFN-α as reported from phase II and III clinical trials. Clinical model parameters were also derived from these trials and complemented with clinical experts’ opinions. Costs of drugs, routine follow-up, treatment-related adverse events, disease progression, and best supportive care of terminally-ill patients were included in the model. Results, expressed as life-years (LY), progression-free LY (PFLY), and quality adjusted LY (QALY) gained, treatment costs (applied in 2008 USD), and incremental cost-effectiveness ratios (ICER), were obtained through probabilistic analysis over a 10-year time horizon. Since the phase III clinical trial of temsirolimus included the MSKCC (modified) poor risk group patients only, two separate evaluations were carried out: (1) comparison of sunitinib, sorafenib, and bevacizumab + IFN-α in all patients and (2) a similar comparison of sunitinib and temsirolimus in the poor-risk group patients only. Results: In the first comparison model, sunitinib was both more effective (with gains of 0.52 and 0.19 PFLY, and 0.17 and 0.03 QALY) and less costly (by $13,675 and $84,260) than sorafenib and bevacizumab + IFN-α, respectively, over 10 years. Similarly, sunitinib was both more effective (with gains of 0.12 PFLY and 0.07 QALY) and less costly (saving $9,605 over ten years) than temsirolimus in patients in the poor risk group. Conclusions: These model results suggest that sunitinib is a cost-effective alternative to sorafenib, bevacizumab + IFN-α, and temsirolimus as a first-line treatment of mRCC.

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Outcome evaluation of patients requiring tracheostomy in an intensive care unit in Trinidad

OBJECTIVE

To evaluate the outcome of patients who have undergone a tracheostomy in a multidisciplinary intensive care unit (ICU) and to determine the difference between an early and late tracheostomy.

DESIGN AND METHODS

All patients who had tracheostomy in the ICU of The Eric Williams Medical Sciences Complex, Trinidad and Tobago, over a five-year period were retrospectively analysed. Data recorded included demographics, admission diagnoses, Glasgow Coma Score, Acute Physiology and Chronic Health Evaluation II score, Paediatric Index of Mortality II score, indication for endotracheal intubation and tracheostomy and the day it was performed, ICU and hospital length of stay and observed mortality. Predicted mortality was calculated. A comparison was made of patients who had tracheostomy before and after ten days following ICU admission. Validation of the prognostic models was done by Receiver Operating Curve (ROC) analysis.

RESULTS

One thousand six-hundred and fourteen patients were admitted to ICU during the study period; 51 patients (3%) underwent tracheostomy, of which 48 were studied. The overall mortality was 19.1% and 40.6% in tracheostomised patients. Patients who had tracheostomy within ten days had a significantly lesser predicted mortality and shorter ICU length of stay than those who had it after ten days (p = 0.01). The observed mortality was also significantly less in early-tracheostomised patients (p < 0.02).

CONCLUSIONS

Tracheostomy should ideally be done within ten days following ICU admission when there is a clear need and indication for the procedure. Further delay may contribute adversely to the ICU morbidity and mortality.

Reliability of the evaluation of students' answers to essay-type questions

INTRODUCTION

This paper seeks to quantify the reliability of the assessment of students' answers to essay-type questions, in an attempt to define the role of such questions in University examinations.

METHODS

The marks awarded for essay-type questions during three consecutive final undergraduate examinations in surgery were analyzed. The mean scores, 95% confidence intervals and the standard error of the mean were calculated to determine the distribution of the marks. Statistical analysis was used to determine the correlation of the marks awarded for the same answer by different markers and deduce the dependability of this method of testing.

RESULTS

The marks awarded to 233 answer papers were available for analysis. The marks awarded by each pair of examiners for student answers to individual questions coincided on only 46.3% of occasions, but varied within just +/- 5% on 90.7% of occasions. Use of the kappa index to determine the agreement between markers produced a value of just 0.385, well short of the ideal of 1.0. Assessment of the overall reliability of this type of examination by Cronbach's reliability coefficent gave a value of 0.672.

CONCLUSION

There was a significant variation among markers in the evaluation of answers to essay-type questions. However; the overall test reliability was acceptable enough to justify continuation of this type of assessment as a supplement to other methods.

Sustained release nanoparticulate formulation containing antioxidant-ellagic acid as potential prophylaxis system for oral administration

The aim of the present work was to develop ellagic acid (EA) loaded poly(d,l-lactide-co-glycolide) (PLGA) nanoparticles for oral administration. PLGA nanoparticles were prepared by a method based on the concept of emulsion-diffusion-evaporation by using polyethylene glycol (PEG) 400 as a cosolvent for solubilizing the drug. While developing this method, didodecyldimethylammomium bromide (DMAB) and polyvinyl alcohol (PVA), alone and in combination with chitosan (CS) were employed. DMAB stabilized particles were the smallest of all the formulations with a particle size of 148.5 nm. PVA alone gave particles of 269.7 nm but a blend with CS (80:20) resulted in an increase in particle size (359.6 +/- 23.6 nm). Initial release of EA from nanoparticles in pH 7.4 phosphate buffer was rapid, followed by a slower sustained release. Release rates followed the order PVA > PVA-CS > DMAB. Release rate from the PLGA-DMAB particles was slowest, which is attributed to higher hydrophobicity of DMAB as compared to PVA, preventing diffusion of drug out of polymeric matrix. Insolubility of CS at alkaline pH could have retarded the release in case of PVA-CS system. In situ intestinal permeability study of pure drug and the drug encapsulated in nanoparticles prepared using PVA, PVA-CS blend and DMAB as stabilizer in rats showed 66, 75, 73 and 87% permeation, respectively. EA showed good free radical scavenging effect in a yeast cell culture model as well as in a cell free system.

A dose-ranging study of the pharmacokinetics and pharmacodynamics of the selective apoptotic antineoplastic drug (SAAND), OSI-461, in patients with advanced cancer, in the fasted and fed state

PURPOSE

To evaluate the safety, pharmacokinetics and determine the recommended dose of the selective apoptotic antineoplastic drug, OSI-461 administered on a twice-daily regimen to patients with advanced solid malignancies.

METHODS

In this phase I trial, 33 patients were treated with OSI-461 doses ranging from 400 to 1,200 mg given twice daily in 4-week cycles. Pharmacokinetic studies were performed to characterize the plasma disposition of OSI-461 and the effect of food intake on OSI-461 absorption. Secondary biomarker studies were performed to assess the biologic activity of OSI-461 including the measurement of pGSK-3beta, a PKG substrate, and pharmacogenetic studies to identify polymorphisms of CYP3A that influence drug metabolism and of ABCG2, involved in drug resistance.

RESULTS

Thirty-three patients were treated with 86 courses of OSI-461. The dose-limiting toxicities were grade 3 abdominal pain, found in one patient at the 1,000 mg BID fed dose level and all patients at the 1,200 mg BID fed dose level. There was also one episode each of grade 3 fatigue and grade 3 constipation at the 1,000 and 1,200 mg BID fed dose levels, respectively. Other common toxicities included mild to moderate fatigue, nausea, anorexia and mild elevation in bilirubin. Pharmacokinetic studies of OSI-461 revealed approximately a twofold increase in AUC(0-24) when OSI-461 was administered with food. An increase in pGSK-3beta post-dose was seen in the majority of patients and was greater at higher dose levels. No patients exhibited CYP3A4 polymorphisms, while 100% of patients were found to have the CYP3A5*3/CYP3A5*3 polymorphism. Two known polymorphisms of the ABCG2 gene, G34 --> A34 and C421 --> A421, occurred at frequencies of 11.76 and 29%, respectively.

CONCLUSIONS

Toxicity and pharmacodynamic data show that the recommended oral dose of OSI-461 is 800 mg twice daily administered with food. The drug appears to be well-tolerated, and overall bioavailability appears to be markedly increased when the drug is administered with food. These results support further disease-directed evaluations of OSI-461 at a dose of 800 mg BID in combination with other chemotherapeutic agents.

BK virus nephritis after renal transplantation

BK virus nephritis is an increasing problem and is posing a threat to improving renal transplant graft survival. The pathogenesis of this condition remains to be investigated. Higher prevalence of BK virus infection in recent years has been correlated with declining acute rejection rates and the use of potent immunosuppressive agents. Patients with this infection usually have asymptomatic viremia and/or nephritis with or without worsening of renal function. The diagnosis of this disease is based on detecting the virus or its effects in urine, blood, and renal tissue. In the past, approximately 30 to 60% of patients with BK virus nephritis developed graft failure. In recent years, the combination of early detection, prompt diagnosis, and therapies including preventive measures have resulted in better outcomes.

Utilization pattern and cost of sedation, analgesia and neuromuscular blockade in a multidisciplinary intensive care unit

OBJECTIVES

To study the utilization pattern and the cost of sedatives, analgesics and neuromuscular blocking agents in a multidisciplinary intensive care unit (ICU).

METHODS

A prospective observational study was conducted in the ICU of the Eric Williams Medical Sciences Complex, Trinidad and Tobago, for a period of twelve weeks. All patients admitted to the ICU were enrolled. No interventions were done. Data collected included demographics, diagnoses on admission, length of stay in the ICU, status of mechanical ventilation, patient outcome, quantity of sedatives, analgesics and neuromuscular blocking agents used in every patient and their cost.

RESULTS

There were 333 patient-days encountered from 34 patients studied. Midazolam, fentanyl and cisatracurium were the most commonly used sedative, opioid and neuromuscular blocking agents respectively. The total cost of drugs used for sedation, analgesia and neuromuscular blockade was approximately US$ 19,600 per annum. Cost for this treatment alone accounted for more than 50% of the total ICU drug costs. The costs were significantly higher in patients who stayed more than two weeks in the ICU when compared to those who stayed less than two weeks (p < 0.001).

CONCLUSIONS

The study highlights the utilization pattern and financial burden of sedation, analgesia and neuromuscular blockade in the delivery of critical care.

Recurrent glomerulonephritis after renal transplantation: an unsolved problem

BACKGROUND AND OBJECTIVES

Despite advances in prevention of acute rejection and improved short- and long-term kidney graft survival, recurrent glomerulonephritis remains problematic and poorly characterized. This study analyzed prevalence and outcome of recurrent glomerulonephritis from various registries.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Definition, classification, and limitations in evaluating epidemiology of native and recurrent glomerulonephritis are discussed. Epidemiology of native glomerulonephritis as the cause of end-stage renal failure and subsequent recurrence of individual glomerulonephritis was evaluated using data from various registries, and pathogenesis of individual glomerulonephritis is discussed.

RESULTS

Analysis of data from transplant registries revealed that glomerulonephritis is an important cause of end-stage renal disease in white and pediatric recipients; however, glomerulonephritis as the cause of end-stage renal disease is not characterized well in black recipients, and many of them are perhaps labeled to have hypertensive nephrosclerosis as the cause of renal disease without renal biopsy. A systematic approach toward urinalysis after transplantation and utility of immunofluorescence and electron microscopic examination of renal biopsy tissues will identify the true prevalence of recurrent glomerulonephritis. Data on recurrent glomerulonephritis should be compiled by either using registry analysis or pooling data from multiple centers. This will provide true data on prevalence and outcome and could potentially initiate translational research studies.

CONCLUSIONS

The understanding of the pathogenesis of recurrent glomerulonephritis is critical to optimize prevention as well as to treat individual recurrent glomerulonephritis, which can enhance long-term graft survival.

Risk-adjusted outcome evaluation in a multidisciplinary intensive care unit

OBJECTIVE

To evaluate the outcome of a multidisciplinary Intensive Care Unit (ICU) by applying the Acute Physiology and Chronic Health Evaluation (APACHE II) and Paediatric Index of Mortality (PIM)--version-2 scoring systems.

SUBJECTS AND METHODS

Two-hundred and seventeen patients admitted consecutively to the ICU during a period of one year were included for prospective data collection. Data recorded were demographics, diagnoses at admission, APACHE II score for adults and PIM -2 score for children, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality ratios were calculated. Calibration and discriminant function of the systems were done by Hosmer-Lemeshow analysis and Receiver Operating Characteristic (ROC) curves.

RESULTS

In adults, the mean APACHE II score was 14.3 +/- 8.3; in survivors, it was 8.7 +/- 5.9 (SD) when compared to 21.2 +/- 5.9 (SD) in non-survivors (p < 0.0001). The predicted mortality in adults by APACHE II was 16.5%, the observed mortality being 19.8%. The predicted mortality by the PIM-2 in children was 34.8% with the observed mortality rate being 30%. The overall mean duration of stay was 5.2 +/- 7.5 days. The goodness-of-fit for APACHE II and PIM-2 systems were fair (HL chi-square, p = 0.71, 0.69, respectively). The area under the ROC curve was 0.88 for APACHE II and 0.62 for PIM-2.

CONCLUSION

Evaluation of risk-adjusted outcome in multidisciplinary ICUs is challenging because of the need to apply more than one prognostic scoring system.

Measuring angles on digitalized radiographic images using Microsoft PowerPoint

OBJECTIVE

To introduce the "virtual goniometer", a method of measuring angles on digital images using Microsoft PowerPoint, a readily available and inexpensive software programme.

METHODS

Twenty-six X-rays of scoliosis curves were photographed with a digital camera. Six examiners measured the angles of curvature on their computers using the goniometer (Set 1). Under a blinded protocol, repeated measurements on these digitalized X-rays were done three weeks later (Set 2). Intra-observer differences were analyzed. To assess validity, four examiners also measured the angles using the Cobb method. Measurements achieved by both methods were analyzed by the paired samples t-test. To assess inter-observer differences, the Pearson correlation coefficient was calculated.

RESULTS

Pearson correlation coefficients were significant, r (24) > or = 0.975, p < 0.001. For intraobserver variability, the average 95% CI range was 2.23 degrees between Set 1 and Set 2. The average 95% CI range was 2.38 degrees for the difference between the digital and Cobb methods.

CONCLUSIONS

Clinicians using this technique can reliably assume that repeated measurements of scoliosis curvatures will vary in the range of less than 3 degrees. The 95% CI range for intra-observer variability, an index of the technique's repeatability, was > or = 2.4 degrees. A high correlation of measurements can also be expected between different observers with the goniometer. This new technique allows practitioners to utilize an easily accessible computer programme to evaluate angular deformities on digitalized radiographic images accurately and hence reliably make clinical decisions based on these measurements.

An evaluation of the intensive care unit resources and utilization in Trinidad

OBJECTIVES

To evaluate resources and utilization of Intensive Care Units in Trinidad and Tobago.

DESIGN AND METHODS

This was a prospective observational study to evaluate Intensive Care Units (ICU) of three public and two private hospitals in Trinidad with respect to their infrastructure, process of care and patient outcome. Structure of ICUs was assessed by interviews and personal observations. A Cost Block Model was used to determine the expenditure for ICUs. The process of ICU was assessed by Therapeutic Intervention Scoring System (TISS-28). For outcome evaluation, two prognostic scoring systems namely Simplified Acute Physiology Score (SAPS II) and Paediatric Index of Mortality-2 (PIM-2) were used

RESULTS

The total number of ICU beds was 27. The overall bed occupancy was 66.2%. One hundred and eighteen patients consecutively admitted to ICU during a two-month period were enrolled for process and outcome evaluation. The overall median age of patients was 44 years [Interquartile range (IQR) 25, 59]. The mean cost per patient in the public hospitals was TT $64,746 compared to $77,000 in a private hospital. The average total daily TISS per patient was 27.01 +/- 5.4 (SD). The median length of stay was five days (IQR 2, 9). The overall predicted mortality was 32.9%, the observed mortality was 29.7% and thus the standardized mortality ratio (SMR) was 0.9.

CONCLUSIONS

The overall bed availability in ICUs with respect to Trinidad and Tobago's population and case-mix is low compared to developed countries, although the process of ICU care is comparable. Outcome of patients was good in terms of risk-adjusted mortality. The study highlights the need to further increase bed-strength and optimize the resource utilization of ICUs in Trinidad and Tobago.

Access to kidney transplantation among patients insured by the United States Department of Veterans Affairs

Ensuring equal access to kidney transplantation is of paramount importance. Veterans that receive care from the Department of Veteran Affairs (VA) must complete a complex process to be placed on the transplant wait-list, and only four VA hospitals in the United States transplant kidneys. This unique system may cause VA patients to wait longer for kidney transplants than other patients. We compared the time to transplantation among ESRD patients insured by the VA to those insured by private insurance or Medicare/Medicaid. Of 7395 veterans studied, 9.3% received transplants, compared to 35,450 of 144,651 (24.5%) patients with private insurance and 36,150 of 357,345 (10.1%) patients with Medicare/Medicaid insurance (P < 0.0001). We found that both VA-insured and Medicare/Medicaid-insured patients were approximately 35% less likely to receive transplants than patients with private insurance (hazard ratio [HR] 0.65; 95% CI 0.60 to 0.70; P < 0.0001). Most of this difference was explained by the fact that VA patients were less likely to be placed on the wait-list (HR 0.71; 95% CI 0.67 to 0.76), but even listed VA patients received transplants less frequently than those insured privately (HR 0.89; 95% CI 0.82 to 0.96). Interestingly, VA patients with supplemental private insurance had the same likelihood of transplantation as non-VA patients with private insurance. We conclude that VA-insured patients are less likely to receive transplants than privately insured patients, and that further studies are needed to identify the reasons for this disparity.

Assessment of the biological and pharmacological effects of the ανβ3 and ανβ5 integrin receptor antagonist, cilengitide (EMD 121974), in patients with advanced solid tumors

BACKGROUND

Cilengitide, an antiangiogenic agent that inhibits the binding of integrins alpha(nu)beta(3) and alpha(nu)beta(5) to the extracellular matrix, was studied at two dose levels in cancer patients to determine the optimal biological dose.

PATIENTS AND METHODS

The doses of cilengitide were 600 or 1200 mg/m(2) as a 1-h infusion twice weekly every 28 days. A novel dose escalation scheme was utilized that relied upon the biological activity rate.

RESULTS

Twenty patients received 50 courses of cilengitide with no dose-limiting toxic effects. The pharmacokinetic (PK) profile revealed a short elimination half-life of 4 h, supporting twice weekly dosing. Of the six soluble angiogenic molecules assessed, only E-selectin increased significantly from baseline. Analysis of tumor microvessel density and gene expression was not informative due to intrapatient tumor heterogeneity. Although several patients with evaluable tumor biopsy pairs did reveal posttreatment increases in tumor and endothelial cell apoptosis, these results did not reach statistical significance due to the aforementioned heterogeneity.

CONCLUSIONS

Cilengitide is a well-tolerated antiangiogenic agent. The biomarkers chosen in this study underscore the difficulty in assessing the biological activity of antiangiogenic agents in the absence of validated biological assays.

Two Years Postconversion From a Prograf-Based Regimen to a Once-Daily Tacrolimus Extended-Release Formulation in Stable Kidney Transplant Recipients

Tacrolimus extended-release (XL) is a once-daily formulation recently developed to reduce the frequency of dosing for patients currently using the twice-a-day formulation of tacrolimus (TAC). As reported previously, 67 kidney transplant recipients were safely converted (1:1 mg basis, total daily dose) from TAC twice-a-day to XL once-daily in the morning and were maintained on an am dosing regimen of XL using the same therapeutic monitoring and patient care techniques currently employed with TAC. The 2-year postconversion patient (100%) and graft (98.5%) survival, incidence of biopsy-confirmed acute rejection (6.0%), incidence of multiple rejections (1.5%), and safety profile (posttransplant diabetes, hyperlipidemia, hypertension, infections, renal dysfunction, hepatic dysfunction, and malignancies) were consistent with or more favorable than those previously reported for TAC twice-a-day.