*Purpose: The SRTR had not traditionally included biopsy results in post-transplant risk adjustment, yet biopsy results may influence outcomes and thus decisions regarding organ acceptance. The aim of this study was to evaluate the impact of donor macrovesicular steatosis on organ yield and graft outcome after liver transplantation, and the effect of incorporating this variable into SRTR risk adjustment models for organ yield and program-specific graft outcomes.

*Methods: This study used data from the Scientific Registry of Transplant Recipients, which includes all donors, waitlisted candidates, and transplant recipients in the United States. We examined the association between macrovesicular steatosis and deceased donor yield, and the relationship between macrovesicular steatosis and 1-year posttransplant graft outcome using multivariable logistic regression and Cox models with the least absolute shrinkage and selection operator (LASSO).

*Results: 3.3% of donors had 31-50% macrovesicular steatosis on liver biopsy, and 1.3% with >50%. Increasing levels of steatosis on donor liver biopsy predicted lower organ yield; 31-50% and >50% macrovesicular steatosis was associated with 88 and 96% lower odds of utilization, respectively (Figure A). The risk of posttransplant graft failure with donor livers with >30% macrovesicular steatosis was 30% higher (HR 1.30), compared to those with no pre-transplant liver biopsy or those with 0-10% macrovesicular steatosis (Figure B). There was minimal change on organ procurement organization (OPO)-specific deceased donor yield or program-specific post-transplant outcome assessments when macrovesicular steatosis was added to the existing SRTR risk adjustment models.

*Conclusions: Macrovesicular steatosis is associated with lower organ yield and reduced graft survival. This risk factor has been added to the SRTR risk adjustment models for OPO and program-specific assessments and may facilitate more judicious use of these higher-risk organs.

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