OBJECTIVE The primary aims were to identify the incidence, etiology and outcome of all adult cases of fulminant hepatic failure (FHF) presenting to the Victorian Liver Transplant Unit over the 14 year period since the Unit was established in 1988. METHODS The database of the Unit was used to identify all adult patients (>16 years) who were referred to the Austin and Repatriation Medical Center in Melbourne with FHF between 1988 and 2001. The Austin and Repatriation Medical Center is the sole provider of adult liver transplantation services for the states of Victoria and Tasmania. RESULTS 80 patients (64 female, 14 male) with FHF were referred, at a rate of approximately one case per million population per year. The mean age was 37.6 +/- 13.7 years. Most cases were due to either paracetamol poisoning n = 29 (36%) or non-A non-B (idiopathic) hepatitis n = 27 (34%). Thirty-five patients were listed for transplantation, of which 26 underwent the procedure (77% of transplantation patients currently alive). Nine patients were listed for transplantation but did not undergo the procedure, eight died before a donor became available and one recovered. Of the 30 patients who survived without transplantation, 20 cases were due to paracetamol poisoning. CONCLUSIONS Liver transplantation has had a major impact on survival of patients with FHF, most significantly in patients with FHF due to causes other than paracetamol poisoning, in whom survival without transplantation is uncommon. Survival in those who undergo transplantation for FHF is excellent, but a significant percentage of patients listed for transplantation die before a donor organ becomes available.