Although 1-year survival rates following liver transplantation over the last 20 years may have improved, there is doubt about improvement in long-term survival. We examined survival with and without initial 12-month mortality in adult liver transplant recipients over a 20-year period. Patient and allograft survival for 3 different time periods was compared: 1986-1994 (group 1, n = 547), 1995-2000 (group 2, n = 735), and 2000-2005 (group 3, n = 749). After this, all deaths in the first 12 months of each group were removed. Patient and allograft survival was then once again compared across the 3 groups. There was significant improvement in both patient and allograft survival across the 20-year period (P < 0.001). Overall patient and allograft survival improved in non–hepatitis C virus (HCV) patients but not in HCV patients. A similar comparison with deaths in the first year removed, however, showed no difference in patient survival (P = 0.07) and only a marginal improvement in allograft survival (P = 0.048) between the 3 time periods. When patients were divided into HCV-positive and HCV-negative groups with deaths in the first year removed, there was, however, improved patient and allograft survival in the HCV-negative group but not in the HCV-positive group. The causes of death between 1 and 5 years were then compared. There were 48 deaths in period 1, 63 in period 2, and 43 in period 3 (P = not significant). There were more deaths due to cardio/cerebrovascular disease and hepatitis B virus recurrence in the first time period, but there were more deaths due to recurrent HCV and de novo malignancy in later time periods. In conclusion, although overall survival following liver transplantation in adults seems to be improving over time, the long-term results are not, particularly in HCV patients. Liver Transpl 16:130–137, 2010. © 2010 AASLD.