*Purpose: The present study represents the largest series of donor livers with moderate macrosteatosis and provides detailed analysis of the effects of post reperfusion syndrome (PRS) and its impact on both short and long-term outcomes. PRS is an immediate complication of hemodynamic instability, asystole or the need to start the infusion of vasopressors during the post-reperfusion period. This study aims to describe the real peri-operative dangers of utilizing donor livers with significant macrosteatosis.

*Methods: Clinical outcomes of all patients undergoing LT with donor livers with Moderate Macrosteatosis (30-60%)(N = 96) between 2000-2017 were compared to a propensity score matched cohort of patients undergoing LT with donor livers with No Steatosis(N = 96).

*Results: Cardiac arrest at the time of reperfusion was seen in 8(8.3%) of the patients in the Moderate Macrosteatosis group compared to 0(0%) of patients in the No Steatosis group (p=0.004). Patients in the Moderate Macrosteatosis group had a higher rate of PRS (37.5%vs.18.8%; p=0.004), early allograft dysfunction (EAD) (76.4%vs.25.8%;p<0.001), renal dysfunction requiring CRRT following transplant (18.8%vs.8.3%;p=0.03) and return to the OR within 30 days (24.0%vs.7.3%;p=0.002), than the No Steatosis Group. Both long-term patient (p=0.08) and graft survival(p=0.12) were not different between the 2 groups.

*Conclusions: Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial peri-operative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.

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