*Purpose: Recently, there has been public scrutiny on the non-utilization of elderly donors in liver transplantation. Here, we evaluate the influence of donor liver biopsy (DLBx) on organ utilization amongst donors over 65 years of age.

*Methods: OPTN Standard Transplant Analysis and Research database was queried for adult donation after brain death donors between 2006 and 2016, identifying 65,781 potential donors. Donors were grouped by age and percent macrosteatosis (MaS) on biopsy. Multivariable logistic regression analyses evaluated factors influencing biopsy performance and organ utilization. Odds ratios (OR) with 95% confidence intervals (CI) are reported. P-values <0.05 were considered significant.

*Results: DLBx was performed in 28,055 (42.6%) potential donors, of which 3,916 were elderly. In multivariable analysis, elderly donors were more likely to have DLBx compared to donors <35 years old (OR 6.09 [95% CI 5.67-6.58], p<0.001). Compared to younger donors, the odds of organ utilization amongst elderly donors without a biopsy was 0.18 [0.16-0.21]; however, with a biopsy the likelihood of utilization increased (OR 0.38 [0.33-0.44], p<0.001 for both). MaS on DLBx was the strongest predictor of organ utilization. Compared to elderly donors without DLBx, MaS <30% on DLBx was associated with increased likelihood of organ utilization (OR 1.24 [1.09-1.42], p<0.001), while organs with ≥30% MaS had significantly decreased utilization (OR 0.21 [0.17-0.27], p<0.001). Interestingly, the utilization of elderly donors with and without DLBx varied significantly across the country.

*Conclusions: Utilization of DLBx for elderly donors, may increase the organ utilization rate by providing evidence of acceptable organ quality.

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