Hypothesis: Older donor grafts will provide suitable results of liver transplant, even in recipients with hepatitis C virus (HCV). Although HCV remains the leading indication for liver transplant in adults in the United States, it is associated with HCV recurrence, increased graft loss, and reduced survival. In addition, recent studies suggest that the use of older donors in recipients with HCV is associated with significantly worsened short- and long-term survival. Design: Prospective database analysis. Setting: Washington University School of Medicine. Patients: Between January 1, 1997, and June 30, 2006, a total of 579 liver transplants were performed. Ninety pediatric transplants were excluded. Of the remaining 489 adult patients (84.5%), 187 (38.2%) had HCV and 302 (61.8%) had other indications. Main Outcome Measures: Patient and graft survival, recurrence ofHCV,andneed forandresults of retransplant. Results: At 1, 3, and 5 years, overall patient survival was 88.1%, 78.3%, and 69.2%, respectively, and graft survival was 85.6%, 75.6%, and 65.6%, respectively, in patients with HCV. There was no significant difference in patient or graft survival between patients with and those without HCV. Recurrent HCV with clinically significant disease was 20% at 1 year and 62% at 10 years. Seventy-two patients received transplants from donors 60 years or older (24 of 187 [12.8%] with HCV and 48 of 302 [15.9%] without HCV). No difference was demonstrated in short- or medium-term patient or graft survival in recipients of grafts from older donors. Conclusion: The increasing use of marginal donors, including carefully selected older donors, does not seem to adversely affect short- or medium-term results and may be a source of additional organs for expanding liver transplant waiting lists.