Background: Macrovesicular steatosis is assumed to be an important risk factor for early allograft dysfunction (EAD) after orthotopic liver transplantation (OLT). Aim: To evaluate the impact of steatosis in combination with other risk factors on the outcome of OLT. Methods: The degree of steatosis was analysed in 165 consecutive OLTs and was classified by histological examination as non (M0), mild (< 30%, M1), moderate (30-60%, M2) or severe steatosis (> 60%, M3). Recipients were analysed for EAD. Results: EAD was observed in 28% of patients with M0, 26% with M1, 53% with M2 and 73% with M3 (P < 0.001). Patients with EAD had a significantly shorter graft survival after liver transplantation (P = 0.005) but did not correlate with survival. In multivariate regression analysis, the grade of steatosis, donating after cardiocirculatory death (DCD) grafts and duration of cold ischaemia time were significantly associated with EAD (P < 0.001, P = 0.01 and P = 0.001, respectively). Conclusion: Livers with severe (M3) steatosis from DCD donors, combined with a prolonged CIT have a high risk for developing EAD which is correlated with shorter graft survival. Therefore M3 livers should only be considered for OLT in selected recipients without the presence of additional risk factors.