Transmission of hepatitis B virus (HBV) infection from donors who are negative for hepatitis B surface antigen (HBsAg-) but positive for antibody to hepatitis B core antigen (anti-HBc+) has been reported. However, previous studies were generally performed in geographic regions with a low prevalence of anti-HBc positivity in the liver donor population. The aims of this study are (1) to assess the risk for de novo hepatitis B in recipients of livers from anti-HBc+ donors in an area of high prevalence of anti-HBc positivity in the donor population, and (2) to analyze the risk factors for acquisition of HBV infection from anti-HBc+ donors. The transplantation experience of a single center between 1995 and 1998 was reviewed. Thirty-three of 268 liver donors (12%) were HBsAg- and anti-HBc+ during the study period. The proportion of anti-HBc+ donors increased with age; it was lowest (3.6%) in donors aged 1 to 20 years and highest (27.1%) in donors aged older than 60 years. Of the 211 HBsAg- recipients with 3 months or more of HBV serological follow-up, 30 received a liver from an anti-HBc+ donor and 181 received a liver from an anti-HBc- donor. Hepatitis B developed in 15 of 30 recipients (50%) of livers from anti-HBc+ donors but in only 3 of 181 recipients (1.7%) of livers from anti-HBc- donors (P < .0001). None of the 4 recipients who were antibody to HBsAg (anti-HBs)+ at the time of transplantation developed HBV infection after receiving a liver from an anti-HBc+ donor compared with 15 of 26 recipients (58%) who were anti-HBs- (P =.10). None of the 5 anti-HBc+ recipients developed hepatitis B compared with 15 of 25 anti-HBc- recipients (60%; P = 0.04). Child-Pugh score was significantly higher in recipients of livers from anti-HBc+ donors who developed HBV infection than in those who did not (9 +/- 2 v 7 +/- 1; P =.03). In our area, testing liver donors for anti-HBc is mandatory, particularly in older donors. With such information available, anti-HBc+ donors can be safely directed to appropriate recipients, mainly those with anti-HBs and/or anti-HBc at the time of transplantation. In the current era of donor shortage, this policy would allow adequate use of such donors.