title: The use of fatty liver grafts in modern allocation systems: risk assessment by the balance of risk (BAR) score.
abstract: OBJECTIVE
  To integrate the amount of hepatic steatosis in modern liver allocation models.
  
  
  BACKGROUND
  The 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.
  
  
  METHODS
  We 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).
  
  
  RESULTS
  Microsteatosis, 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.
  
  
  CONCLUSIONS
  Microsteatotic 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.
authors.affiliation: Swiss HPB and Transplant Center, Department of Surgery, University Hospital Zurich, Switzerland.
authors.forename: Philipp
authors.initials: P
authors.lastname: Dutkowski
authors.forename: Andrea
authors.initials: A
authors.lastname: Schlegel
authors.forename: Ksenija
authors.initials: K
authors.lastname: Slankamenac
authors.forename: Christian E
authors.initials: CE
authors.lastname: Oberkofler
authors.forename: Rene
authors.initials: R
authors.lastname: Adam
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Burroughs
authors.forename: Eric
authors.initials: E
authors.lastname: Schadde
authors.forename: Beat
authors.initials: B
authors.lastname: Müllhaupt
authors.forename: Pierre-Alain
authors.initials: PA
authors.lastname: Clavien
mesh_terms: D001706:Biopsy; D005060:Europe / Q000453:epidemiology; D005234:Fatty Liver / Q000473:pathology*; D005260:Female; D006085:Graft Survival; D006801:Humans; D016031:Liver Transplantation / Q000401:mortality / Q000473:pathology; D008297:Male; D017063:Outcome Assessment, Health Care; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D014019:Tissue Donors; D014184:Transplantation, Homologous; D014481:United States / Q000453:epidemiology