Acetaminophen overdose is the leading cause of acute liver failure in the United States. A substantial proportion of these patients survive with conservative treatment. Liver transplantation is the only definite therapy that significantly increases chances of survival in irreversible liver failure. While it is estimated that 5-year survival after liver transplantation for acetaminophen-induced hepatic failure exceeds 70%, the psychiatric outcomes of these patients are not well known.

We identified seven patients who underwent liver transplantation for acetaminophen-induced acute hepatic failure between 1994 and 2011 at a Midwestern transplant center performing more than 100 liver transplantations per year. Six patients consented to research participation and their charts were reviewed. All patients were females with average age at transplant of 34.3 years. Two overdoses were unintentional and four were suicide attempts. All patients were diagnosed with depressive disorder prior to overdose and two had alcohol abuse histories. One patient had two prior suicide attempts and diagnosis of borderline personality disorder. On average, patients were listed for liver transplantation three days after overdose and then underwent transplantation two days later. In the years following transplantation, two patients experienced acute episodes of rejection due to poor immunosuppressant medication compliance. One patient had another suicide attempt with acetaminophen overdose ten years after her liver transplantation and was then lost to follow-up. The remaining five patients are surviving on average 5 years after transplant. Detailed data on patients’ medical and psychiatric outcomes is presented.

Our experience suggests that patients undergoing liver transplantation in the immediate aftermath of acetaminophen overdose are likely to have had pre-transplant psychiatric illness and are at high risk for recurrent post-transplant psychopathology. We comprehensively review the unique challenges facing the transplant teams assessing these patients’ candidacy for liver transplantation. The specific factors associated with treatment noncompliance and poor transplant outcomes are reviewed in detail.

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