Successful Use of Extended Criteria Donor Grafts With Low to Moderate Steatosis in Patients With Model for End-Stage Liver Disease Scores Below 27 A.W. Avolio, F. Frongillo, N. Nicolotti, A. Mulè, G. Vennarecci, P. De Simone, and S. Agnes ABSTRACT Liver transplantation may be performed using extended criteria donor grafts (ECDg). The characteristics of ECDg include age 60 years, long intensive care unit (ICU) stay, history of malignancy or steatosis. Grafts are often discarded due to steatosis, which can be macrovesicular (MaS) or microvesicular (MiS). MaS is the variety most frequently involved with unfavorable outcomes due to primary nonfunction (PNF) or primary dysfunction (PDF). As of January 2000, all livers referred to our institution were considered potentially transplantable. Steatosis was defined as the presence of fat droplets in more than 5% of hepatocytes. We observed 35 steatotic grafts. Grafts were stratified according to MaS and MiS as follows: low steatosis (5%–15%), mild steatosis (16%–30%), moderate steatosis (31%– 60%), or severe steatosis (60%). Fifteen grafts with moderate (n = 2) or severe (n = 13) MaS were discarded. Twenty grafts were harvested: 18 of them were transplanted at our institution, the remaining 2, discarded by our donor team, were transplanted by other Italian centers. Low MaS was detected in 10 grafts (50%), mild MaS in 4 (20%), and moderate MaS in 2 (10%). Low MiS was detected in 8 grafts (40%), mild MiS in 5 (25%), and moderate MiS in 1 (5%). Steatotic grafts were transplanted only into recipients with model for end-stage liver disease (MELD) scores 27. The 6-month graft survival was 80%; the PNF rate was 10%; and the PDF rate was 15%. The careful use of ECDg with low to moderate steatosis is possible if particular care is taken to avoid additional risk factors related to the recipient. T TODAY LIVER TRANSPLANTATION cannot be performed without the use of extended criteria donor grafts (ECDg). The characteristics of ECDg include age 60 years, long intensive care unit (ICU) stay, history of malignancy or steatosis. Although no precise definition of ECDg is widely accepted, deceased donor liver transplan- tation grafts are often discarded due to steatosis. In papers on donor liver steatosis, 1–5 steatosis has recently been named nonalcoholic fatty liver disease (NAFLD), with a 10% to 30% prevalence in the general population. 6,7 It occurs at all ages, commonly reported on ultrasound screening. However, a small number of individuals with NAFLD, which is basically considered a benign condition, progress to more severe stages of liver disease, including nonalcoholic steato- hepatitis (NASH) with or without fibrosis. Obviously, the problem involves a large portion of the donor pool. Steatosis can be macrovesicular or microvesicular. Mac- rovesicular steatosis (MaS) is the variety most commonly involved with unfavorable outcomes after transplantation as a result of a high prevalence of primary nonfunction (PNF) or primary dysfunction (PDF). 1,3,8 Microvesicular steatosis (MiS), which shows a more favorable prognosis, can be combined with MaS in mixed varieties. 9 However, the degree of such condition, as represented by the type of steatosis, is expressed by the percentage of affected hepa- From Department of Surgery – Transplantation Service (A.W.A., F.F., S.A.), Department of Hygiene and Epidemiology (N.N.), Department of Pathology (A.M.) “A.Gemelli” Catholic University of Rome, Italy; Department of General Surgery and Liver Transplantation (G.V.), “San Camillo Hospital”, Rome, Italy; and the Liver Transplant and General Surgery Unit (P.D.S.), “Cisanello Hospital,” Pisa, Italy. Address reprint requests to Alfonso Wolfango Avolio, MD, Department of Surgery, Catholic University of Rome, L. go Gemelli 8, Rome 00168, Italy. E-mail: alfonso.avolio@rm. unicatt.it 0041-1345/09/$–see front matter © 2009 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2008.10.050 360 Park Avenue South, New York, NY 10010-1710 208 Transplantation Proceedings, 41, 208 –212 (2009)