With an increase in the prevalence of MASLD in the United States population, what recipient and donor characteristics do you find favorable for acceptance of a highly steatotic graft?

There are many different clinical and biochemical features that our surgical colleagues assess when considering potential donor liver grafts, the degree of histological steatosis being one of them. Concurrent presence of fibrosis on biopsy is important to consider, as well as the degree of micro- and macrosteatosis. The hormonal and other physiological changes that accompany brain death often lead to microvesicular steatosis that may be rapidly reversible after implantation. Highly steatotic donor grafts are currently considered "extended" donors that may convey an increased risk of primary non-function or poor early graft function. Longer cold ischemic times or patients anticipated to have more complicated surgeries (i.e., presence of port...

Traditionally, macrovesicular steatosis above 30% in cadaveric donors and above 20% in living donors was considered a relatively no-go. But livers of younger donors (ideally <50 years old without major comorbidities) may have a better chance for regeneration (with less than 50% steatosis) and could be used for transplants in recipients that have lower MELD scores ( I personally prefer lower than <18-24), no significant portal hypertension, and younger <60 years old). Some transplant oncology candidates meet these criteria (i.e., colorectal cancer metastasis, otherwise healthy liver). Although machine perfusion has increased the utilization of these grafts, programs will need to discuss at the time of offer, which of the selected recipients ...