*Purpose: Novel methods to assess steatosis, such as proton density fat fraction (PDFF) from MRI provide an accurate and continuous quantification of mild steatosis. We hypothesized that assessment of steatosis with PDFF could identify and risk-stratify live donors without the need for a liver biopsy.

*Methods: Mild steatosis was defined as a PDFF 6.4-17.4%, moderate 17.4-22.1%, and severe>22.1%. PDFF was obtained as standard of care in all of our live donors evaluated between June 2018 and September 2019 at University of Pittsburgh Medical Center. In the recipients, we collected laboratories during the first posttransplant week along with clinical outcomes including standard definitions for primary non-function (PNF), early allograft dysfunction (EAD), and small for size syndrome (SFSS).

*Results: Out of 86 potential donors, 60 (70%) had no steatosis and 27 (30%) had steatosis (mild in 23 [85%], moderate and severe in 2 [7%] each). Forty-six (53%) proceeded with donation, all with mild steatosis (maximum PDFF 16.4%). The average PDFF for donors with steatosis was 9.9±2.5% and 2.9±1.3% in its absence (p<0.001), with no distinct features between donors with or without steatotic livers (age 42±9 vs. 37±10; White 91 vs. 97; BMI 28±3 vs. 26±4). Recipients of a steatotic liver were slightly older 64±7 than those without steatosis (57±13; p=0.02), however, there were no differences when considering biologically related donation (46% vs. 39%; p=0.7), graft weight to recipient weight ratio (1.1±0.4 vs. 1.1±0.2; p=0.9) or MELD (15±8 vs. 16±6; p=0.7). We found no significant differences in post-transplant labs and length of hospital stay (8 [7-11] vs. 10 [7-15] days) between recipients receiving a graft with or without steatosis (all p’s>0.05), and no cases of EAD, PNF or SFSS were identified. There were 3 graft losses / recipient deaths, 2 in the group without steatosis and 1 in the group with steatosis, related to hepatic artery thrombosis, multiorgan failure, and mesenteric ischemia.

*Conclusions: Noninvasive assessment of steatosis with PDFF allowed the identification of live donor allografts suitable for transplantation. Although transplant outcomes using allografts with a PDFF above 16.4% cannot be known, our findings support the use of PDFF to predict successful transplantation when donors with no or mild steatosis are considered.

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