Abstract
The growing prevalence of fatty liver disease in donor livers has become a critical focus in liver transplantation due to the global shortage of viable grafts. This article reviews the challenges and advancements in utilizing steatotic donor livers, emphasizing their increased risk of post-transplant complications, such as primary non-function and early allograft dysfunction. Mechanistically, macrovesicular and microvesicular steatosis differentially impair lipid metabolism, exacerbate ischemia-reperfusion injury (IRI), and disrupt hepatic microcirculation, contributing to graft failure. Innovations in donor assessment, including magnetic resonance imaging-proton density fat fraction and AI-enhanced imaging, have improved fat quantification accuracy, while machine perfusion techniques (e.g., hypothermic oxygenated perfusion and normothermic machine perfusion) show promise in mitigating IRI and enhancing preservation, particularly for marginal steatotic livers. However, controversies persist regarding standardized fat-content thresholds, ischemia tolerance limits, and heterogeneity in risk stratification. Future research highlights the need for non-invasive subtyping technologies, dynamic preservation strategies guided by real-time biomarkers, and multi-omics approaches to unravel steatosis-related molecular pathways. Addressing these challenges may expand the safe use of steatotic grafts and alleviate organ shortages.