Prior variceal bleeding may adversely affect the prognosis of orthotopic liver transplantation. We studied this question by evaluating all 175 adult patients undergoing orthotopic liver transplantation at our institution to determine risk factors associated with mortality after transplantation. Seventy patients demonstrated prior variceal bleeding, and of those, 32 had a course of sclerotherapy. Thirteen also had portal systemic shunts. Compared with the 105 transplant patients who had no prior bleeding, patients who bled were more likely to have parenchymal liver disease (74% vs. 50%), equally likely to have cholestatic liver disease (19%), and less likely to have malignancy (6% vs. 19%) or fulminant liver failure (1% vs. 12%). Bleeding patients also were more likely to be Child-Pugh class C (46% vs. 35%). By the common closing date of December 31, 1990, 26 patients (37%) with prior bleeding and 48 patients (46%) without bleeding died after transplantation. From survival curves, patients with prior bleeding had improved survival rates at 1 yr (65% vs. 54%), at 3 yr (60% vs. 47%) and at 5 yr (55% vs. 43%), although the differences were not statistically significant. With a proportional hazards model to adjust for confounding effects, the relative risk of mortality among patients with prior bleeding was 0.60 (95% confidence interval, 0.27 to 1.30). Sclerotherapy or portal systemic shunts did not alter survival. Important adverse risk factors for mortality included older age at transplantation, black race, malignant disease and more advanced Child-Pugh class. This study suggests that prior esophageal variceal bleeding did not adversely affect the mortality of patients undergoing orthotopic liver transplantation. (HEPA-