*Purpose: The number of steatotic deceased donor livers encountered has continued to rise as a result of the obesity epidemic. Little is known about the histological characteristics of moderately macrosteatotic livers over time in the recipient following liver transplantation (LT).

*Methods: All recipients undergoing LT at Mayo Clinic Florida (MCF) with donor livers with moderate macrosteatosis (30-60%) from 2000-2017 were identified (N=96). Routine protocol liver biopsies were performed 1 week and 6 months following LT. All liver donor and protocol biopsies were read by an experienced liver pathologist at MCF.

*Results: Of the 96 moderate macrosteatosis LTs, 70 recipients had post-LT protocol liver biopsies available and therefore comprised the study cohort. Median donor allograft macrosteatosis at the time of transplant was 33% (IQR 30-40%) compared to 0% (IQR 0-2%) at 1 week (p<0.001) and 0% (IQR 0-0%) at 6 months (p<0.001) following LT. Biopsies at 1 week post-LT displayed pericentral necrosis in 57.1% of recipients and lipopeliosis in 34.3% of recipients. In the 6 month post-LT biopsies cholestasis was seen in 3 (4.3%) of recipients, while grade 2 fibrosis was seen in 6 recipients (8.6%). Graft survival at 5 years in the present cohort was 75.3%.

*Conclusions: Moderate Macrosteatosis (30-60%) in the donor allograft demonstrates complete reversal on liver biopsies performed as early as 7 days following LT and remains absent at 6 months following LT. Both pericentral necrosis and lipopeliosis are common features on day 7 biopsies. Longterm graft survival is excellent in recipients who are able to overcome the immediate perioperative risk of utilizing moderately steatotic donor livers.

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