*Purpose: To determine which subcategories of marginal livers have seen advancements in utilization and which have not.

*Methods: 181,992 eligible donors listed in the Organ Procurement and Transplantation Database from 1995-2019 were retrospectively analyzed. Five different definitions were used to classify a donor as marginal: 90th percentile donor risk index, donation after cardiac death, age >70, >30% macrovesicular steatosis, and 90th percentile discard risk index. Standard criteria donors were defined as not meeting any of these definitions. Multivariate logistic regression was used to compare utilization over time.

*Results: The study population is comprised of 187,124 eligible donors from 1995-2019. Of these eligible donors, 75% (n=140,268) had their livers utilized for transplant, and 22% (n=40,946) were classified as marginal. Overall liver utilization has remained stable, peaking in 2003 at 82% before decreasing over time to 70% in 2019. Likewise, marginal liver utilization peaked in 2003 at 63% and subsequently decreased over time to 37% in 2019. From 1995 to 2019 the number of eligible marginal donors increased at an exponential rate (R²=0.952) comprising 58% of the increase in total eligible donors during this time. Despite this, the utilization of marginal allografts has not changed significantly (43% in 1995 to 38% in 2019). The average donor risk index of all eligible donors has increased from 1.37 in 1995 to 1.58 in 2019.

*Conclusions: The increase in eligible liver donors has been driven by an exponential increase in the number of marginal donors, however utilization remains steady. An increase in the relative utilization of these marginal donors may be a potential source for further growth in the donor supply.

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