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Introduction: Previous reports have indicated an association between blood transfusion and prognosis of hepatocellular carcinoma (HCC) after hepatectomy. However, clinicopathological biases were not adjusted in these studies. We aimed to clarify the effect of blood transfusions in patients with HCC and Child-Pugh class A after hepatectomy by using inverse probability of treatment weighting (IPTW) analysis for selection bias control. Materials and methods: We enrolled 479 patients with primary HCC and Child-Pugh class A retrospectively (91 transfused and 388 nontransfused patients) who underwent curative hepatectomy. After adjusting for different covariate distributions for both groups by IPTW, we analyzed the prognostic outcomes. Results: In the unweighted analyses, overall survival (OS) rate of transfused patients was significantly lower than in nontransfused patients ( P < 0.0001). Recurrence-free survival (RFS) rate of transfused patients was significantly lower than that of nontransfused patients ( P = 0.0024). Multivariate analysis showed that blood transfusion was an independent prognostic factor of OS and RFS. The different distributive covariates between the two groups were age, presence of liver cirrhosis, serum level of alpha-fetoprotein, maximum tumor diameter, and amount of intraoperative blood loss. After IPTW by these covariates, OS rate of transfused patients was not significantly lower than those of nontransfused patients, whereas RFS rate of transfused patients remained significantly lower than those of nontransfused patients ( P = 0.038, adjusted HR 1.45; 95 % CI 1.0-2.1). Conclusions: These results suggest that blood transfusion was associated with recurrence of HCC after hepatectomy in patients with HCC and Child-Pugh class A. [ABSTRACT FROM AUTHOR]