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The presence of perioperative use of voriconazole in this predictive model validates our logistic model. The predictive model may be especially helpful in situations where a risk assessment of hepatotoxicity outside the perioperative period is desired. One may question why we did not monitor voriconazole levels and use a specific threshold as a possible predictor of hepatotoxicity. Monitoring of voriconazole serum level has been proposed to optimize therapeutic efficacy and minimize toxicity (2). Hepatotoxicity has been associated with high serum voriconazole levels, however, prospective data to support this association are limited and controversial (9�C14). Several authors reported an association between hepatotoxicity and serum voriconazole levels higher than 6 mg/L (9�C11,14). Others described a possible association without http://www.selleckchem.com/products/ly2157299.html reporting a threshold for hepatotoxicity (12,13). A large retrospective analysis of 10 clinical trials reported an association between hepatotoxicity and incremental rise in voriconazole concentration; however, no threshold for toxicity could be established (15). The authors concluded that the mean voriconazole levels may not be a useful marker for prediction of hepatotoxicity. Of note, the majority of these studies did not assess for potential confounders such as medication, ischemic injuries, presence of graft-versus-host disease and acute infection. In contrast, other studies examined http://www.selleck.cn/products/XL184.html the relationship between serum voriconazole level and hepatotoxicity and found no association (16�C18). Troke et al. examined voriconazole exposure�Cresponse relationships for patients from nine published clinical trials and found no association between voriconazole serum level higher than 5 mg/L and toxicity (18). As such, while there may be an association between hepatotoxicity and elevated serum voriconazole levels, the benefit of serum level monitoring to predict hepatotoxicity remains uncertain. Unfortunately, voriconazole serum levels were not available at our institution and thus we cannot comment on the relationship between serum voriconazole levels and hepatotoxicity. Our study has some important limitations. First, a larger study http://www.selleckchem.com/products/z-vad-fmk.html would have provided greater statistical power to detect additional risk factors (i.e. reducing the false-negative rate) as well as develop a refined scoring system for hepatotoxicity. Although other risk factors for hepatotoxicity could have been included in multivariable analysis, standard statistical techniques suggest using 1 variable for every 10 outcomes (17). Due to the limited number of measured outcomes, the multivariable analysis was restricted to five variables, which appeared most significant (p value