• Philipp Dutkowski, Andrea Schlegel, Ksenija Slankamenac, Christian E Oberkofler, Rene Adam, Andrew K Burroughs, Eric Schadde, Beat Müllhaupt, and Pierre-Alain Clavien.
• Swiss HPB and Transplant Center, Department of Surgery, University Hospital Zurich, Switzerland.
• Ann. Surg. 2012 Nov 1; 256 (5): 861-8; discussion 868-9.

ObjectiveTo integrate the amount of hepatic steatosis in modern liver allocation models.BackgroundThe aim of this study was to combine the 2 largest liver transplant databases (United States and Europe) in 1 comprehensive model to predict outcome after liver transplantation, with a novel focus on the impact of the presence of steatosis in the graft.MethodsWe adjusted the balance of risk (BAR) score for its application to the European Liver Transplant Registry (ELTR) database containing 11,942 patients. All liver transplants from ELTR and United Network for Organ Sharing with recorded liver biopsies were then combined in one survival analysis in relation to the presence of graft micro- (n = 9,677) and macrosteatosis (n = 11,516).ResultsMicrosteatosis, regardless of the amount, was associated with a similar relationship between mortality and BAR score as nonsteatotic livers. Low-grade macrosteatotic liver grafts (≤30% macrosteatosis) resulted in 5-year graft-survival rates of 60% or more up to BAR 18, comparable to nonsteatotic grafts. However, use of moderate or severely steatotic liver grafts (>30% macrosteatosis) resulted in acceptable outcome only if the cumulative risk at transplant was low, that is, BAR score of 9 or less.ConclusionsMicrosteatotic or 30% or less macrosteatotic liver grafts can be used safely up to BAR score of 18 or less, but liver grafts with more than 30% macrosteatotis should be used with risk adjustment, that is, up to BAR score of 9 or less.

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