With appropriate selection criteria, patients with end-stage alcoholic liver disease who undergo orthotopic liver transplantation have similar graft and patient survivals as patients undergoing transplantation for other causes. However, because of the possibility of recidivism after orthotopic liver transplantation there is still reluctance to transplant alcoholic patients. This study examined the association between pretransplant psychosocial variables and the risk of recidivism after orthotopic liver transplantation. At our institution, 43 patients received orthotopic liver transplantation for the referral diagnosis of alcoholic liver disease from February 1, 1988 to May 1, 1991. This represented 17% of all first transplants (43 of 257) performed during this period. Patients were interviewed before orthotopic liver transplantation by a single psychiatrist and responses to a defined set of questions were entered into a clinical database. All 43 patients diagnosed with alcoholic liver disease and a comparison group of patients transplanted for diagnoses other than alcoholic liver disease received a postoperative questionnaire regarding past and present alcohol use. Patients enrolled in the study all had at least 7 mo of follow-up, with the median follow-up being 21 mo. Eighty-six percent of alcoholic liver disease patients (37 of 43) and 86% of patients in the comparison group (37 of 43) of ALD patients agreed to participate in the study. Nineteen percent of alcoholic liver disease patients (7 of 37) and 24% of patients in the comparison group (9 of 37) admitted to having used alcohol after orthotopic liver transplantation, with 8% (3 of 37) and 11% (4 of 37) currently using alcohol, respectively. No association between amount or duration of alcohol used before liver transplantation and recidivism was found in patients with alcoholic liver disease. Binge use of alcohol, history of driving under the influence of alcohol, history of alcohol withdrawal, and other drug use also were not associated with recidivism in alcoholic liver disease patients. Patients who participated in in-patient or out-patient rehabilitation programs before or after transplantation, or who admitted they were alcoholics, had similar rates of recidivism. Being married, employed or having a history of psychiatric symptoms requiring treatment were not associated with recidivism rates in alcoholic liver disease patients. Finally, after multivariate analysis only one variable was associated with recidivism in alcoholic liver disease patients, sobriety less than 6 mo. These findings support the selection criterion of abstinence from alcohol for > 6 mo before alcoholic liver disease patients undergo orthotopic liver transplantation.