*Purpose: This study aims to evaluate regional trends in liver transplantation (LT) among adults in the United States (US) with nonalcoholic steatohepatitis (NASH), with particular emphasis on changing trends before and after introduction of direct-acting antiviral agents for hepatitis C (HCV).

*Methods: Using data from the United Network for Organ Sharing (UNOS) LT database, we evaluated diseased donor liver transplants and waitlist registration for patients listed for transplant with NASH cirrhosis in the US between January 1, 2004, and December 31, 2019. Main outcomes included national and regional trends in liver transplant and waitlist registration for NASH. Regional data was stratified as established by the Organ Procurement and Transplantation Network (OPTN).

*Results: Between 2004-2019, the annual total number of LT for NASH increased consistently. A total of 11,198 transplants were performed on patients listed for NASH during the study period, the majority (57.0%) of which were transplanted in the post-HCV treatment era between 2014 and 2019. OPTN Region 3 performed the most total LT for NASH over the study period (n=2314), while Region 6 performed the least total LT for NASH (n=218). Every OPTN region showed an increase in total number of LT performed over the study period, with the majority of regions growing most precipitously between 2014-2019. In the post-HCV era, annual LT for NASH grew the most in OPTN Region 5 (207.5%), followed by Region 1 (193.8%) and Region 4 (183.3). Regions 2 (136.5%), 8 (124.5%), 7 (120.4%), and 9 (111.1%) showed relatively moderate growth in total LT between 2014-2019, while Regions 10 (96.8%), 6 (89.5%), 3 (87.4%), and 11 (76.1%) showed mild growth in LT for NASH.

*Conclusions: Total LT for patients with NASH has dramatically increased in the US particularly since 2014, suggesting changing trends of transplantation allocation in the post-HCV era. Heterogeneity of regional growth rate in LT for NASH may be accounted by the regional variation in prevalence of NASH and regional LT policies for NASH. The consistent growth of LT for NASH across all OPTN regions demonstrates a paradigm shift of future liver transplantation.

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