Letter to the Editor: Additional viewpoints from transplant surgeons on Banff consensus recommendations for the assessment of steatotic donor livers

To the editor, We read with great interest the article by Neil et al.1 The utilization of severely macrovesicular steatotic donor livers may result in grave consequences, such as primary nonfunction of the liver allograft; hence, an accurate assessment of steatotic livers is imperative. Given the lack of uniformity in pathological criteria and variations in pathologists' assessments, the precise evaluation of hepatic steatosis poses a formidable challenge for transplant teams. The pathological assessment criteria and algorithmic approach established by Neil et al hold significant promise for accurately discerning hepatic steatosis in donor livers. However, several issues deserve further discussion and investigation from the perspective of transplant surgeons. First, when establishing an algorithmic approach, it is advisable to include more cases of severe hepatic steatosis. Admittedly, severe macrovesicular steatosis of donor livers is generally less likely to be considered for transplantation2; however, the limited number of severe steatotic liver cases in this study may raise potential bias in algorithm development resulting in assessment mistakes. Second, clarification regarding the timing of pathological specimen collection is warranted. In fact, liver assessment may occur at various intervals, such as donor maintenance, preorgan retrieval, postretrieval, and pretransplantation. Simultaneously, the comprehensive evaluation of cold ischemia time and the degree of hepatic steatosis will also impact surgeons' decisions regarding the utilization of the donor liver. Given that hepatic steatosis may evolve during donor maintenance and postretrieval storage,3 it is crucial to emphasize the importance of time-zero liver allograft biopsies acquisition to surgeons. Lastly, the algorithmic approach established by Neil was exclusively conducted based on frozen sections. Although uncommon in clinical practice, some transplant centers, such as the Division of Liver and Transplant Pathology at the University of Pittsburgh, possess the capability to prepare rapid paraffin sections.4 In addition, the accuracy of assessing hepatic steatosis degree on frozen sections may be slightly inferior to that on paraffin sections.5 Thus, it raises the question of whether a certain degree of error occurs when extending the algorithmic approach to other forms of pathological sections. In summary, confronting the increased donor liver steatosis rate and the lack of uniform pathological assessment standards, Banff consensus recommendations hold significant promise for accurately assessing hepatic steatosis. It is believed that addressing the above issues is instrumental in facilitating the clinical implementation of Banff consensus recommendations.