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Case. A 30-year-old male chronic schizophrenic, presented to the general physicians 36–48 h after ingesting 40 g of paracetamol. His paracetamol level at this time was 1 mmolul. He had no history of previous self harming episodes, drug or alcohol abuse. He was referred to the renal service 1 day after admission. At this point he was haemodynamically stable, anuric, euvolaemic and encephalopathic (grade II). Repeat paracetamol level was 0.46 mmolul. He was acidotic with a venous bicarbonate level of 17 mmolul. There was evidence of severe hepatic injury with an ALT of 11 968 IUul (peaking the following day at 18 876 IUul). His bilirubin was 117 mmolul and hepatic synthetic function was grossly deranged, as evidenced by an INR of 4.0 (peaking 2 days later at 7.0). Serum creatinine was elevated at 364 mmolul. The patient was persistently hypoglycaemic and required a glucose infusion. Initial management consisted of intravenous N-acetyl cysteine, 5% glucose fluid challenge (to elevate central venous pressure to 8 cm H2O) and a single dose of 500 mg of frusemide (with no effect on urine output). Discussion took place with the local hepatic transplant centre. They declined the transfer of the patient, on the grounds of his chronic psychiatric illness. It was therefore decided to treat the patient with albumin dialysis using the molecular absorbents recirculating system (MARS, Teraklin AG, Germany). This system is described in more detail in a variety of publications w1,2x. A standard dialysis monitor manages the extracorporeal blood circuit and generates the dialysate solution. The MARS monitor was connected to a Hospal Integra dialysis monitor and we performed a course of five consecutive 8-h treatments. Over this treatment period there were considerable improvements in both clinical and biochemical indices. His level of consciousness returned to normal after two treatments. His acidosis was corrected, bile acids fell from 108 mmolul to 22 mmolul (Figure 1), plasma ammonia fell from 140 mmolul to 51 mmolul, INR fell from a peak of 7.0 to 1.1 and bilirubin to 176 mmolul. He was discharged after 26 days, having required dialysis alone for a further 9 days. Serum creatinine and liver function tests had returned to within normal limits within 1 month of discharge from hospital.