*Purpose: Macrosteatosis (MaS) identified on donor liver biopsy (DLBx) influences organ utilization but alone is not predictive of outcomes following liver transplantation (LT). Here we present a simple scoring system to risk stratify LT following DLBx.

*Methods: The OPTN Standard Transplant Analysis and Research database was queried for adult, deceased donor LT between 2006 and 2016. Using recipient MELD score, donor Age, Cold ischemic time, and allograft Steatosis, the MACS score was developed. Risk groups were identified based on trends in survival: Low, Mild, Moderate, High, and Severe. Logistic regression analyses assessed risk of graft loss. Risk ratios (RR) with 95% confidence intervals (CI) are reported. P-values <0.05 were considered significant.

*Results: Amongst 41,351 transplants, 14,809 (35.8%) had DLBx. Thirty-day and 1-year graft loss varied significantly across all five Risk groups. Risk of 30-day graft loss was similar between LT recipients without DLBx and Low and Mild Risk groups (RR 0.87 [95% CI 0.74-1.03, p=0.10] and RR 1.029 [0.87-1.22, p=0.74], respectively). Risk of graft loss was highest for High Risk (RR 1.69 [1.35-2.13], p<0.001) and Severe Risk groups (RR 2.39 [1.95-2.92], p<0.001). Risk of 1-year graft loss remained highest for Severe Risk recipients (RR 1.78 [1.55-2.05], p<0.001). Notably, Low Risk recipients had significantly decreased risk of graft loss at 1-year than LT without DLBx (RR 0.88 [0.80-0.97], p=0.009).

*Conclusions: DLBx is a useful adjunct for evaluating marginal donors. The MACS is a simple score which can be used to risk stratify LT and inform organ allocation and outcomes with marginal organs.

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