Thirty-three patients with acute liver failure underwent orthotopic liver transplantation, including 16 with fulminant hepatic failure, 15 with late-onset hepatic failure and two with severe acute liver failure (coagulopathy without encephalopathy). Twenty-three (70 per cent) survived to leave hospital and 21 of these are currently alive and well. Outcome correlated with the serum bilirubin level before transplantation (p less than 0.05) but no correlation was found with the variant of acute liver failure, grade of encephalopathy, cerebral oedema, serum creatinine, white cell count, prothrombin time or platelet count at the time of transplantation. Severe coagulation factor deficiencies did not constitute a clinical problem. One patient developed a neurological deficit secondary to cerebral oedema, but otherwise the morbidity reflected that observed in the general population after transplantation. Careful monitoring of intracranial pressure and surveillance (with early aggressive therapy) for bacterial and fungal infections is very important in achieving a successful outcome after transplantation.