Recurrent hepatitis B virus (HBV) infection in the liver allograft is a significant cause of morbidity and mortality in those transplanted for chronic HBV disease. A detailed histological and immunohistochemical study of recurrent HBV disease in liver allografts was carried out using archival paraffin-embedded tissue. A total of 34 follow-up liver biopsies from 14 patients transplanted for HBV were available for study. In addition to routine stains, sections were stained with antibodies to a range of HBV antigens. Two patients transplanted for acute HBV remained free of re-infection. Five of seven patients transplanted for chronic HBV disease who were followed-up, developed HBV-associated cirrhosis 12–23 months later. Hepatocyte ballooning, high nucleocapsid antigen load, ductular proliferation and immature fibrous tissue characterized this unusual cirrhosis, which developed rapidly from fibrosing cholestatic hepatitis in at least three cases. Death from liver failure supervened quickly in three of the five patients. These findings support the concept that HBV infection in the liver allograft can be a different disease from that occurring in the non-transplant setting, and may be related to high antigen load.