The aim of this study was to determine the influence of donor graft steatosis on overall outcome, viral recurrence, and fibrosis progression in orthotopic liver transplantation (OLT) for hepatitis C virus (HCV) cirrhosis. One hundred twenty patients who underwent OLT for HCV cirrhosis between 1995 and 2005 were included in the study. Donor steatosis was categorized as absent (0%-10%; n ϭ 40), mild (10%-30%; n ϭ 32), moderate (30%-60%; n ϭ 29), or severe (Ͼ60%; n ϭ 19). A Cox multivariate analysis for marginal donor variables and a Model for End-Stage Liver Disease index were performed. Fibrosis evolution was analyzed in liver biopsies (fibrosis Ͻ 2 or Ն2) 3, 6, and 12 months post-OLT and in the late post-OLT period. Fifty-six grafts were lost (46%). The survival of the grafts was inversely proportional to donor liver steatosis: 82%, 72%, and 72% at 1, 2, and 3 years post-OLT in the absence of steatosis; 73%, 63%, and 58% with mild steatosis; 74%, 62%, and 43% with moderate steatosis; and 62%, 49%, and 42% with severe steatosis (P ϭ 0.012). HCV recurrence was earlier and more frequent in recipients with steatosis Ͼ 30% (46% versus 32% at 3 months, P ϭ 0.017; 58% versus 43% at 6 months, P ϭ 0.020; 70% versus 56% at 12 months, P ϭ 0.058; and 95% versus 69% at 3 years post-OLT, P ϭ 0.0001). Graft survival was lower in alcoholic liver disease recipients versus HCV recipients when steatosis was Ͼ30% at 3, 6, and 12 months post-OLT (P ϭ 0.042) but not when steatosis was Ͻ30% (P ϭ 0.53). A higher fibrosis score was obtained 3 months post-OLT (P ϭ 0.033), 6 months post-OLT (P ϭ 0.306), 12 months post-OLT (P ϭ 0.035), and in the late post-OLT period (P ϭ 0.009). In conclusion, donor graft steatosis influences the outcome of OLT for HCV cirrhosis. HCV recurrence is more frequent and earlier in recipients of moderately and severely steatotic livers. Fibrosis evolution is higher when graft steatosis is Ͼ30%. OLT with Ͼ30% steatotic donor livers should be precluded in HCV recipients.