Transmission of hepatitis B infection from hepatitis B surface antigen (HBsAg)-negative antibody to hepatitis B core (anti-HBc)-positive liver donors has been previously described. The long-term outcome of these transplant-associated de novo hepatitis B patients has not been well described and may affect future use of donor organs that are anti-HBc-positive. We describe the experience in our first 332 transplants, performed before exclusion of anti-HBc-positive liver donors. Nine of these 332 (3%) donors were anti-HBc positive. Three of these 9 (33%) recipients developed transplant-associated de novo hepatitis B infections compared with only 2 of 323 (0.5%) recipients who received anti-HBc-negative donor livers (P = .00014). Of our 9 recipients of anti-HBc-positive livers, 6 (67%) are alive, and no deaths or allograft failures have been related to complications of hepatitis B. Only 1 of 5 patients (20%) with de novo hepatitis B has developed significant graft dysfunction with an average follow-up of more than 7 years (range 63-124 months). The 1 recipient with allograft dysfunction related to de novo hepatitis B has significantly elevated viremia levels (average HBV DNA 460 pg/mL) compared with the other de novo hepatitis B recipients (average HBV DNA 23-58 pg/mL). In summary, anti-HBc-positive donors are more likely to transmit hepatitis B infections to recipients, but these de novo infections usually have a mild clinical course and do not seem to adversely affect long-term patient survival. Hepatitis B-related allograft dysfunction, when it occurs, is associated with higher levels of viral replication. With our current donor shortage, perhaps anti-HBc-positive donors could be used in very selected recipient populations.