We have retrospectively reviewed the first 308 patients undergoing orthotopic liver transplantation (OLTX) at our institution to determine the following: 1) To what extent does renal function deteriorate postoperatively? 2) To what extent does renal function recover after OLTX for hepatorenal syndrome (HRS)? 3) What is the survival rate of patients with HRS compared with those without HRS? In non-HRS patients, GFR declined from 97.1 +/- 2.9 cc/min to 56.6 +/- 2.4 cc/min at 6 weeks postoperative, 62.6 +/- 2.6 cc/min at 1 year, and 58.3 +/- 3.5 cc/min at 2 years. In HRS patients, GFR increased from 19.9 +/- 3.6 cc/min to 32.5 +/- 3.1 cc/min at 6 weeks, 45.9 +/- 5.5 cc/min at 1 year, and 37.9 +/- 5.9 cc/min at 2 years. Dosages of cyclosporine were comparable in both groups. There was no difference in perioperative (90-day) mortality. One- and 2-year actuarial survival rates in the non-HRS patients were 87.2% and 82.1%, respectively. The actuarial 1- and 2-year survival rate for the HRS patients was 76.6% (P = NS). Ten percent of HRS patients developed ESRD posttransplant compared with 0.8% of non-HRS patients (P less than 0.005). We conclude that patients with HRS can safely undergo OLTX with acceptable perioperative mortality and good long-term survival. Most HRS patients have return of acceptable renal function. Patients without HRS have a severe decline in GFR posttransplant, which is stable up to 3 years posttransplant.