Orthotopic liver transplantation (OLT) is the only effective treatment for end-stage liver disease due to primary sclerosing cholangitis (PSC). Recurrence of PSC has recently emerged as a leading cause of allograft failure in the long term. There is limited data on risk factors for recurrence of PSC. We performed a retrospective analysis of 69 consecutive patients who underwent a first OLT for PSC over a 14-year period. Baseline characteristics and clinical and laboratory test results post-LT were recorded. Cholangiograms and liver histopathology were reviewed in a blinded manner by an experienced radiologist and hepatopathologist. Recurrent PSC was diagnosed using previously published Mayo Clinic cholangiographic or histologic criteria. Of 69 patients, 7 (10%) developed recurrent PSC at a median of 68 months (range, 24-134 months) post-LT. The following variables were associated with recurrent PSC in our cohort: presence of human leukocyte antigen (HLA)-DRB1*08 (29% versus 2%; P= 0.026; odds ratio [OR], 24.4; 95% confidence interval [CI], 1.8-318.1), acute cellular rejection (ACR) (71% versus 22%; P= 0.015; OR, 8.7; 95% CI, 1.5-49.9), and steroid-resistant ACR (29% versus 0%; P= 0.012). Despite the strong linkage disequilibrium between DRB1*08 and DQB1*04, DRB1*08-positive subjects with recurrence were negative for DQB1*04, whereas the single DRB1*08-positive subject without recurrent PSC was positive for DQB1*04. A history of ACR and presence of HLA-DRB1*08 are associated with increased risk of recurrent PSC, suggesting an immunologic mechanism for this syndrome. Further studies are required to confirm these observations and to understand the underlying mechanisms.