Mortality of fulminant hepatic failure with standard supportive therapy is high (80 to 85%), but unfortunately most patients present to hospital already in Grade IV encephalopathy with severe liver dysfunction, and many have secondary organ damage. If seen earlier, during Grade III encephalopathy, recent experience with charcoal hemoperfusion can give good results (65% survival). Transplantation has a place in those patients who do not respond, and in cases with early Grade IV encephalopathy. Transplantation should also be considered in patients with subacute hepatic failure in whom mortality is equally high and progression to cirrhosis may occur in those who recover. In both groups, the ability to correct the hemorrhagic diathesis and an adequate supply of donor organs are essential to achievement of a successful transplant at this critical time.