Bone disease has emerged as a serious and complex complication after liver transplantation. The purpose of this study is to determine risk factors for fracture and bone loss after liver transplantation. Dual-energy x-ray absorptiometry (DEXA) of the lumbar spine was performed routinely pretransplantation, 6 months posttransplantation, and at yearly intervals thereafter at our center. We followed up patients who underwent transplantation in the past 10 years and compared bone mineral density (BMD) and fracture rate with known risk factors for bone loss in primary transplant recipients who met the inclusion criteria of a pretransplantation DEXA and at least one follow-up DEXA scan postoperatively (n = 153). We observed a 15% (n = 23) prevalence of symptomatic fractures at a mean of 2.2 ± 1.8 years after transplantation. Change in BMD was greatest from pretransplantation to 6 months posttransplantation (-4.2%; P = .006), then increased at a rate of 1.4% per year. Logistic regression analysis showed an association of fracture risk with several factors, including number of acute rejection episodes (P = .045), smoking (P = .02), and female sex (P = .02). Stepwise logistic regression analysis reported female sex (P = .004) as the only factor associated with fracture after transplantation. Age, time listed for transplantation, race, menopause, chronic renal insufficiency, loss of height, family history of osteoporosis, BMD, and T score did not predict fracture or bone loss after transplantation. In conclusion, serial measurements of BMD at the lumbar spine do not appear to predict fracture risk; however, data suggest that female sex is the strongest predictor of fracture after liver transplantation.