The current contradiction of the growing number of patients needing a liver transplant and the severe shortage of available livers is intensifying. A primary challenge in the transplant field is the expansion of the use of “marginal donor livers”. Past experiences indicate that donor livers with moderate or greater macrovesicular steatosis (MaS) of > 30% have an increased risk of early allograft dysfunction and primary non-function after transplantation. Insufficient understanding of the risks associated with steatotic liver grafts has led to higher rates of donor liver discard and adverse outcomes in recipients. These clinical challenges necessitate the safe use of steatotic donor livers. In this context, the work of Steggerda et al. 1 who developed and validated the Liver Transplant After Biopsy (LTAB) and Mini-LTAB scores from a nationwide U.S. database represents a paradigm shift by introducing a dynamic, composite risk assessment that integrates key donor and recipient factors to establish a quantitative standard for evaluating steatotic donor livers. These scores also provide objective evidence for decision-making regarding the use and assessment of a donor liver, doctor-patient communication, and risk mitigation. The authority of traditional histopathological grading in guiding the use of steatotic donor livers has been challenged by the experience of transplant centers. Real-world evidence shows successful long-term outcomes even with moderate (30%–60%) to severe (> 60%) MaS in carefully selected recipients 2, 3. Steggerda et al. also reported equivalent 1-year survival using grafts with up to 50% MaS in recipients with a model for end-stage liver disease (MELD) score of 170) categories. For example, a potential donor liver from a 40-year-old donor with 30% MaS allocated to a recipient with a MELD-Na score of 24 and a CIT of 6 h yields a Mini-LTAB score of 117 (low risk). However, if the donor age is 55 years and the recipient MELD-Na score is 30, the Mini-LTAB score increases to 135 (moderate risk). If the CIT is prolonged to 10 h, the Mini-LTAB score increases to 175 (high risk) 1. This tool embodies precision medicine by guiding the allocation of marginal livers to suitable recipients 5. The Mini-LTAB score is used to steer the allocation of lower-quality steatotic grafts toward the recipients most likely to benefit, thereby maximizing overall transplant outcomes. When discussing the risks and benefits of using a marginal graft, the Mini-LTAB score serves as an objective communication aid that helps patients and their families understand the potential trade-offs, thus facilitating informed consent. Such scoring tools need to be combined with a comprehensive clinical assessment, as recipients who require mechanical ventilation before surgery or have portal vein thrombosis are classified as high risk. However, a limitation of the Mini-LTAB score is that this evaluation model does not consider the impact of emerging machine perfusion techniques on improving organ quality and prognosis. In addition to the established application of living donor liver transplantation and split liver transplantation to expand the donor pool, the First Affiliated Hospital of Guangxi Medical University has also achieved favorable outcomes through extensive practice in using marginal donor livers. While the matching of donor livers is guided by the Mini-LTAB score, particular attention is paid to the recipient's infection status, donor liver function, and minimization of the CIT. Recipients receiving strictly screened marginal steatotic donor livers achieve comparable prognoses to those reported in the literature 2, 3. However, transplantation centers must have a comprehensive supportive care system, and the routine use of donor livers with a high Mini-LTAB score is still not recommended. The study by Steggerda et al. represents an important advance in addressing the donor liver shortage and shows that both donor and recipient factors should be considered when determining whether a marginal donor liver can be used safely. The growing number of patients waiting for liver transplantation suggests that clinicians must become wiser and braver in using every available organ to save lives. Yongyuan Jian: writing – original draft, resources, conceptualization. Cheng Zhang: formal analysis, investigation. Chunqiang Dong: supervision, formal analysis. Kun Dong: writing – review and editing, writing – original draft. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing is not applicable to this article as no datasets were generated or analysed.
Jian et al. (Thu,) studied this question.