Hepatitis C virus (HCV) has a very high disease burden worldwide and is currently the leading cause of liver transplantation. Post-transplant reinfection of the liver graft is universal and progression to recurrent hepatitis and fibrosis as well as clinical decompensation can occur at an accelerated rate. Numerous risk factors for recurrence and rapid progression have been identified. Pre- and post-transplant management, diagnosis of recurrence and the decision to treat with antiviral therapy are complex. This review will focus on patterns of liver injury with HCV, risk factors for recurrence, and post-transplant diagnosis and management. The available data on the effect of HCV on combined liver kidney transplant will also be reviewed.