The charts of 238 patients with systemic lupus erythematosus (SLE) were reviewed. Although not routinely screened for biochemical evidence of liver disease, 124 of 206 patients tested had at least one abnormal result, and 43 met strict criteria for the existence of liver disease. In most patients, a specific viral or drug etiology could not be implicated. The spectrum of liver disease in 33 patients from whom liver tissue was available included cirrhosis, chronic active hepatitis, granulomatous hepatitis, chronic persistent hepatitis and steatosis. Three of four cirrhotic patients demonstrated a peculiar form of cholestasis which resembled a "canalicular cast" of bile. Of the nine patients who had serial liver biopsies, four showed progression of their disease. Three patients died of liver failure. Liver involvement in SLE is more common than previously recognized. Severe and even fatal liver disease can occur.