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cal conditions that present as acute liver failure. A typical situation might be a young, troubled person who is drinking and decides to take an overdose of acetaminophen. Acetaminophen toxicity itself could cause liver failure; however, alcohol increases the risk due to its increase of toxic metabolites. Treatment is usually effective; however, when it is not, acute liver failure may be fatal without transplantation. More often these patients are already confused, comatose and may rapidly develop increased intracranial pressure. Because of their mental status, it may be impossible to interview them. Often from family you can get a history of depression, personality problems or substance abuse. Sometimes the problems appear out of the blue to the family. In many cases a decision will be made to transplant even in a situations where suicide was a clear intent. Depression is potentially a treatable condition and suicidality might be a transient state. Conversely, in situations where you have young adults who have clear histories of intractable substance abuse or severe antisocial personalities you may decide it is not a reasonable risk. In situations where you decide not to transplant, it is important to clearly inform the family regarding the rationale for the decision and refer to other institutions if possible.

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