To determine the prevalence and severity of alcohol-related liver injury in patients with alcoholic liver disease who received liver transplantation, the authors retrospectively reviewed the records of 68 patients with alcoholic liver disease prior to transplant and assessed the incidence of return to drinking and outcome after liver transplant. Ten patients had coexistent chronic viral hepatitis. Mean followup was 42 months. Six of 68 patients (8%) returned to heavy drinking and 3 (4%) died of alcoholic hepatitis at 9 months, 2.5 and 3.5 years after transplant. None of these patients had coexistent viral hepatitis. In two of these patients, pre-mortem liver biopsy showed alcoholic hepatitis in addition to bridging fibrosis and cirrhosis. Of the 57 patients surviving more than 3 months post-transplant, 4 of the 8 patients (50%) who had steatosis and Mallory's alcoholic hyalin in the explant returned to heavy drinking as compared to only 2 of 49 patients (4%) without these histologic findings. Although the incidence of heavy drinking post-transplant was infrequent, fatal alcoholic hepatitis occurred in 50% of patients with this behavior. The presence of steatosis and Mallory's alcoholic hyalin in the pre-transplant histology, indicative of continued alcoholism, predicts recidivism with heavy alcoholic intake and the likelihood of poor survival related to severe graft alcoholic hepatitis.