Autonomic dysfunction is a recognized complication of end-stage liver disease (ESLD), but there is little information on how liver transplantation (LT) affects this problem. We sought to prospectively evaluate autonomic function in patients with ESLD before and after LT. Autonomic reflex screen (ARS) was performed on 30 patients with ESLD prior to transplantation. A 10-point composite autonomic score (CAS) was calculated from these data. ARS was repeated after LT, and these scores were compared with the pre-LT ARS. Thirty patients (25 male, 5 female) with cirrhosis that were listed for LT were enrolled in the study and underwent ARS prior to LT. The average age was 55.4 ฯฎ 9.1 years. Indications for LT included hepatitis C virus ( 14), cryptogenic cirrhosis (5), alcoholic cirrhosis (4), and other (7). The mean native Model for End-Stage Liver Disease (MELD) score at ARS was 17.0 ฯฎ 5.0. Prior to LT, 86.7% of patients had evidence of autonomic dysfunction. Mean CAS was 2.7 ฯฎ 2.2. Sudomotor function was disturbed in 66%, parasympathetic function was disturbed in 57%, and adrenergic function was disturbed in 37%. There was no relationship between pre-LT CAS and age, gender, diabetes, etiology of liver disease, or MELD score. Twenty-one patients (17 male, 4 female) had repeat ARS a mean of 9 ฯฎ 6.2 months after LT. The mean native MELD score at the time of ARS testing was 18.1 ฯฎ 4.3. Mean pre-LT CAS in this group was 3.0 ฯฎ 2.4. Pretransplant CAS was not related to age, gender, diabetes, or MELD score. Autonomic dysfunction improved after LT (CAS pre-LT, 3.0, versus CAS post-LT, 1.9, P ฯญ 0.02). There was no relationship between post-LT CAS and age, gender, diabetes, etiology of liver disease, immunosuppression, or type of transplant. In conclusion, autonomic dysfunction is common in patients with ESLD, with over 86% having abnormal testing. Sixty-three percent of patients with cirrhosis with autonomic dysfunction show improvement after LT.