The 55-year-old, previously healthy patient presented himself with a drop in performance and yellowing of the skin which had persisted for 3 weeks. To strengthen the immune system, he had been taking 7 different Chinese herbs for 4 months. Clinical findings included jaundice, tenderness in the right upper abdomen and grade I encephalopathy (HE).Laboratory revealed coagulopathy as well as elevated transaminases and cholestasis parameters with only slightly elevated ammonia levels. Sonographically, fibrosis or cirrhosis as well as perfusion disorder could be excluded.Due to the temporal course and the lack of previous hepatic disease, acute liver failure (ALF) was diagnosed, caused by the intake of Chinese herbs.Due to an ambivalent patient's will, referral to a transplant center and listing for transplantation were delayed. After liver transplantation graft failure developed as a result of an abdominal compartment syndrome. During the high-risk re-transplantation, a thrombus formed in the right ventricle with a fatal outcome.Timely recognition and referral of a patient with acute liver failure (HE and INR ≥ 2) is crucial.