The care of an infant with primary hyperoxaluria and oxalosis is discussed. After an unheralded presentation, followed by 9 months of intensive treatment that included combined hemodialysis and peritoneal dialysis, the infant successfully underwent combined liver and kidney transplantation to definitely address both kidney failure and the underlying metabolic defect. Discussion of this approach, including ongoing input from the parents, addresses both the implications of undertaking the "best therapy" for this disease as well as the ethical dilemma passed by the decision whether to proceed or not to proceed with therapy.