Background : Traditionally, liver needle biopsy has been considered the gold standard for selecting fatty liver donors in liver transplantation. However, liver biopsy carries procedural risks and complications. Recent advancements in imaging modalities, such as magnetic resonance spectroscopy (MRS), suggest that it alone can be a reliable tool to evaluate fatty liver donors. This study evaluates the evolution of diagnostic strategies over 13 years, emphasizing the shift from invasive to non-invasive methods for donor selection.

Methods : From July 2011 to April 2024, 3541 registered donors were screened, identifying 504 with fatty liver on CT imaging, and final 210 underwent further evaluation. The study was divided into three periods: Period 1 (2011-2016), Period 2 (2017-2021), and Period 3 (2022-2024). Liver biopsy practices transitioned from frequent (Period 1) to selective (Period 2) and rare (Period 3), as MRS became the primary diagnostic tool.

Results : The use of liver biopsies decreased significantly over time (47.4% vs 18.9% vs 4.3%, p<0.001). MRS fat fraction values were consistent across periods (p=0.128), with improvements observed after reminding donors for diet. Despite the reduced use of biopsies, there was no significant difference in fatty liver donor selection among the periods (p=0.438). MRS showed a strong correlation with macrosteatosis percentage from permanent graft biopsy, demonstrating its reliability as a non-invasive diagnostic method.

Conclusions : This study highlights the paradigm shift from liver biopsy to MRS as the primary tool for fatty liver donor evaluation. MR fat fraction reliably correlates with final graft biopsy outcomes, reducing the need for invasive procedure while maintaining effective selection.