*Purpose: The aim of this study is to assess the diagnostic yield of selective pre-donation liver biopsy in living donor liver candidates and its impact on donor selection.

*Methods: We reviewed all liver biopsies performed at our center from 8/1/2016 to 10/5/2020 as part of living donor liver evaluation. Donors underwent pre-donation protocol biopsy if any of the following were present: BMI≥28 kg/m², positive anti-nuclear or smooth muscle antibody, 1^st degree relative of recipient with autoimmune liver disease (AILD) (PSC, PBC, AIH), heterozygote (Hz) for alpha-1-antitrypsin (A1AT) deficiency, steatosis on cross-sectional imaging, or at discretion of evaluating hepatologist. All donors who did not meet criteria for pre-donation biopsy underwent intraoperative biopsy at time of donation.

*Results: A total of 70 pre-donation liver biopsies were performed (27% of donors evaluated during this time). The leading indication for biopsy was BMI>28 (43%), ANA (27%), 1^st degree relative with AILD (17%), A1AT Hz (13%). A total of 19 patients (27%) had abnormal biopsies. Of these, 11 (16% of total donors biopsied) were excluded from donation based on biopsy results. Steatohepatitis was the most common histologic abnormality that precluded donation (5/11) followed by non-specific portal inflammation (3/11). Of 30 patients with a BMI>28, 6 had abnormal biopsies (including 4 who had steatohepatitis). Of 18 patients with positive ANA, only 3 had abnormal biopsies, all of whom had high titer ANA (≥1:160). Of 12 patients biopsied due to 1^st degree relative with AILD (included 4 with positive ANA), all had normal biopsies. No patients that were A1AT heterozygotes (9) had abnormal biopsies (including PAS-D granules). No major complications of donor biopsies were reported. All intraoperative donor biopsies of individuals that did not meet criteria for pre-donation biopsy were normal.

*Conclusions: Liver biopsy remains an important component of living liver donor evaluation, however, more focused patient selection criteria should be considered and ideally, be informed by additional multicenter studies.

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