*Purpose: Careful selection of suitable DCD donor livers is critical to obtain optimal transplant outcomes. In order to identify potentially suitable livers prior to DCD recoveries, we perform routine pre-procurement image-guided percutaneous liver biopsies with surrogate consent on potential DCD liver donors, with the exception of young donors with BMI < 25 kg/m² and without risk factors for or signs of liver disease. The purpose of this study was to examine the impact of pre-procurement liver biopsy on utilization of livers from DCD donors.

*Methods: We retrospectively reviewed demographics, liver histology, and liver disposition of DCD donors who underwent pre-procurement liver biopsy from January 2000 through December 2019.

*Results: Over a 20-year period, 219 DCD donors underwent pre-procurement liver biopsy. Twenty-eight (12.8%) donors were ruled out for liver donation based on biopsy findings, while 191 (87.2%) were deemed suitable for liver recovery and transplant. Of those donors ruled out for transplant based on histology, 11 (39.3%) were under 50 years old, and 10 (35.7%) had BMI < 30 kg/m²; four (14.3%) were under 50 years old with a BMI < 30 kg/m². Of those with acceptable biopsies, 66 (34.6%) were over 50 years old and 16 (8.4%) were over 60 years old. Seventy-two (37.7%) donors with acceptable biopsies had a BMI > 30 kg/m², while 32 (16.8%) had a BMI > 35 kg/m². Twenty-seven (14.1%) donors with acceptable biopsies were both over the age of 50 and had BMI > 30 kg/m². No donors were lost due to complications from biopsy. Of the 191 livers with acceptable biopsies, 146 were successfully transplanted, 28 were deemed not suitable for transplant after recovery or intraoperative evaluation, and 17 were not recovered due to prolonged warm ischemia time or inability to allocate prior to recovery.

*Conclusions: Pre-procurement liver biopsy ruled out 12.8% of DCD donor livers for transplant prior to recovery, and facilitated the successful recovery and transplant of two-thirds of potential DCD donor livers. Over half of livers ruled out by biopsy were from donors under age 50 and/or with BMI < 30 kg/m², while the majority of those donors with acceptable biopsies were 50 years or older and/or obese. Pre-procurement biopsy is a useful technique for evaluating potential DCD liver donors, allowing the surgeon to rule out unsuitable donors prior to deploying resources, and to identify usable livers that might otherwise be ruled out for transplant based on donor age or BMI. Consideration of liver biopsy in this group benefits organ procurement organizations and transplant centers by maximizing organ utilization and optimizing resource deployment.

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