Objective: To determine if the use of steatotic grafts adversely affects outcomes in liver transplantation. Design: A retrospective review of a prospectively maintained database. Setting: A single center. Patients: Four hundred ninety adultswhounderwent liver transplantation from January 1, 2002, to December 31, 2008, at a single center. Graft biopsies were available in 310 (63.3%) cases. Grafts were classified based on amount of macrovesicular steatosis: 5% or less (n=222), more than 5% to less than 35% (n=66), and 35% or more (n=22). Main Outcome Measures: Recipient demographics, Model for End-Stage Liver Disease (MELD) score, patient/ graft survival, complications, transfusion rates, and liver function test results. Results: One-, 3-, and 5-year patient and graft survivals, respectively, were similar (90.38%, 84.7%, and 74.4%, respectively, P=.3; and 88.7%, 82.5%, and 73.3%, respectively, P=.15). Median follow-up was 25 months. Recipient age, sex, body mass index, laboratory MELD score, and ischemia times were similar among all groups. Packed red blood cell (3 vs 8 U, P < .001), fresh frozen plasma (2 vs 4 U, P=.007), and cryoprecipitate transfusion rates were significantly increased in grafts with 35% or more steatosis. Intensive care unit (5 vs 11 days, P=.02) and hospital (11 vs 21 days, P < .001) stay was also increased in those with grafts with 35% or more steatosis compared with those with 5% or less steatosis. The grafts with 35% or more steatosis had higher transaminase peaks and longer times for bilirubin to normalize (P < .001). Conclusions: Use of carefully selected steatotic grafts was not associated with higher rates of primary nonfunction or poorer outcomes. However, the use of steatotic grafts is associated with increased resource use in the perioperative period.