Biotransformation of amides occurs primarily in the liver. Prilocaine is also metabolized in the plasma and kidney, and one of its metabolites may lead to methemoglobinemia. Esters are biotransformed by plasma cholinesterase (pseudocholinesterase). Patients with pseudocholinesterase deficiency may be expected to metabolize ester local anesthetics more slowly. However, at normal doses, this has little clinical effect. Reduced hepatic function predisposes the patient to toxic effects but should not significantly increase the duration of action of local anesthetics.