Fatty liver and kidney syndrome and hepatic steatosis also can occur. No dose adjustment is needed for patients with renal impairment and moderate hepatic impairment. These diseases begin with fatty accumulation in the liver (hepatic steatosis). Trifluoperazine should be used with caution in patients suffering from renal or hepatic impairment. Bile elimination follows hepatic and/or extrahepatic metabolism. Phenobarbital is a cytochrome P450 hepatic enzyme inducer. Toxicity may also include hypotension, blindness and hepatic necrosis. Patients with a history of orthostatic hypotension or severe hepatic impairment. Specifically, it is effective as secondary prevention of hepatic encephalopathy in people with cirrhosis. It is contraindicated in patients with advanced malignant hepatic tumors. The symptomatic phase coincides with elevated hepatic aminotransferase levels. Lactulose is therefore effective in treating hepatic encephalopathy. This syndrome consists of fever, rash, peripheral leukocytosis, lymphadenopathy, and occasionally hepatic necrosis. The diagnosis of minimal hepatic encephalopathy requires neuropsychological testing by definition. Patients with acute hepatic porphyrias should be monitored for HCC.