Introduction: Steatosis assessment in donor livers are very important to evaluate the quality of the liver graft especially in organ donors with high body mass index (BMI) or history of alcohol use. Many liver transplant programs consider 30% macro-steatosis as cut off to use the liver graft. Many donor livers were discarded due to pathology report. Micro steatosis is considered to have less negative impact for the outcome of liver transplantation. However, definition of Macro steatosis and Micro steatosis may be slight difference between the group of the pathologist. Recently, Banff consensus recommendations was published. Recently, we experienced pathology report affected transplant program on the acceptance/ decline of the liver graft. We analyzed our recent experience based on the recommendations 

Method: Between Jan 2020 and Dec 2022, 212 liver transplants were performed in our center. Prospectively, we accumulate and analyzed our patient outcome date in our liver transplant data base system. We collected Liver biopsy information from UNET portal attachment for organ offers from OPO. We identified the liver offer, which were rejected in all other centers due to the pathology report due to steatosis of the liver. We analyzed this specific case.   

Results: Donor was 67 years old female, with 5 ft 3 in, 247lbs, BMI 44. Cause of death was anoxia. Bedside liver biopsy was done.  As reported in Banff consensus recommendations for steatosis assessment in donor livers (Hepatology 2022;75: 1014-1025), there are 3 different reading of macro and micro steatosis reports. First pathologist in local hospital read 5% macro, 70% micro. The second agency pathologist read 0% macro, 0% Large Droplet, 0% micro. The third agency pathologist read 40% macro, 0% micro.  Slides and pathology reports were uploaded to online system through UNET. All transplant centers except us declined the offers. Based on Consensus guideline, radiological and laboratory results, we considered to accept the offer and did liver transplant. Recipient did very well. Extubated on the table. All initial and remote liver function test were excellent. No sign of liver dysfunction.

Conclusion: There is no consensus criteria or approaches regarding steatosis assessment in donor liver biopsy. Three different definition of the macro steatosis exists such as bigger than nucleus, bigger than half of cell size, and bigger than hepatocyte. Recently proposed Banff recommendation, Large Droplet Fat (LDF) may be more accurate for assess the risk of initial poor graft function after liver transplantation. Use of LDF may reduce the discard rate for graft liver and save more patient’s life.