Troglitazone is a new treatment for type 2 diabetes. ALT > 3X upper limit of normal has been reported in 1.9% of patients in clinical trials. This 55 y.o. woman developed dark urine 2 months after starting treatment but continued taking the drug for an additional 1.5 months before stopping. She was not undergoing ALT monitoring. During the following two weeks she developed jaundice and encephalopathy. She underwent orthotopic liver transplantation 3 weeks after stopping the drug. This woman is among about 30+ who have died or undergone transplantation from among about 0.5 million at risk. About 1 per 1,000 develop overt liver disease and about 1 per 10,000+ have died or been transplanted. No patients are reported who were being monitored with monthly ALT, underscoring the importance of surveillance in preventing this unfortunate circumstance.