*Purpose: Accepting a liver with macrosteatosis might increase the risk of adverse post-transplant outcomes, however candidates who decline must then wait for an uncertain future offer. We sought to characterize the survival benefit of accepting a macrosteatotic liver compared to declining and waiting for another offer.

*Methods: We used SRTR data from 2010-2016 to identify candidates who were offered livers with at least moderate macrosteatosis (≥ 30% on liver biopsy) that were eventually accepted by someone. We followed candidates from the date of decision (accept or decline) until death or end of the study period, irrespective of subsequent transplantation or removal from the waitlist. We used adjusted Cox regression to quantify the survival benefit of accepting a macrosteatotic liver compared to declining and waiting for another offer, and used interaction terms to determine whether this survival benefit varied by candidate age, MELD, and BMI.

*Results: We identified 1,132 candidates who accepted and 31,050 who declined a macrosteatotic liver. Overall 1-year survival for those who accepted vs. declined was 89.0% vs 83.0%, and 5-year survival was 78.7% vs. 61.0% (p<0.001) (Figure 1). After declining, only 44.6% of candidates were subsequently transplanted within 6 years, whereas 24.3% of candidates died, 25.8% were removed for worsening condition, and 5.3% were still waiting (Figure 2). Following a brief perioperative risk within the first month of acceptance (adjusted HR: _1.792.40_3.21, p<0.001), accepting a macrosteatotic liver was associated with a 65% reduced risk of mortality (adjusted HR: _0.290.35_0.42, p<0.001). This long-term survival benefit did not vary for candidates with BMI ≥ 30, MELD score ≥ 35, or age ≥ 60 years (p>0.1 for interaction terms).

*Conclusions: Accepting a macrosteatotic liver was associated with substantial survival benefit, even across higher risk subgroups.

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