Background and Aims:Hepatocellular iron accumulation in patients with chronic liver disease has been linked to adverse outcomes. The objective of this study was to identify clinical factors associated with hemosiderosis. Methods: A total of 103 consecutive liver transplant recipients were identified, in whom liver biopsy had been performed prior to transplanta-tion. Laboratory and clinical data at biopsy and transplant were abstracted from the medical records and hepatocyte iron was graded in the biopsy and explant. The association of change in iron score from biopsy to transplant, with the time interval between these two events, was examined using linear mixed model analysis for repeated measures. Results:Most subjects had advanced fibrosis (F3-F4) at liver biopsy, which was performed on average about 2.5 years before transplant. Over 80％ of patients had no or 1+ hepatocyte iron at biopsy;iron increased between biopsy and transplant in about 40％. The only demographic or clinical feature that correlated with increased iron was the presence of a trans-jugular intrahepatic portosystemic shunt. Increased iron at transplant was associated with higher serum iron and trans-ferrin saturation at biopsy, and with lower hemoglobin level, greater mean corpuscular volume, mean corpuscular hemo-globin and mean corpuscular hemoglobin concentration, higher ferritin and model for end-stage liver disease score at transplant. Conclusions: The development of hemoside-rosis in end-stage liver disease is associated with lower he-moglobin levels and alterations in red blood cell indices that are suggestive of hemolysis. These observations suggest that extravascular hemolysis may play a role in the development of secondary iron overload.