Steatotic liver disease is the dominant indication for liver transplantation in both europe and the United States: Trends and outcomes in the past two decades.

Background: Regional differences in liver transplantation (LT) may exist. We described liver transplant populations in the U.S. and European transplant centers over two decades.

Methods: Data from two large LT registries: The United States Scientific Registry of Transplant Recipients (SRTR), and The European Liver Transplant Registry (ELTR), years 2000-2022 were compared.

Results: There were 109,048 transplant recipients from ELTR (30 countries), 128,765 from SRTR with a higher proportion of hepatocellular carcinoma (HCC) in ELTR (29% vs. 20%). Chronic hepatitis B (CHB) (9% vs. 3%) and alcohol-associated liver disease (ALD) (30% vs. 23%) occurred more frequently among European transplant recipients; chronic hepatitis C (CHC) (18% vs. 27%) and NASH/MASH (7% vs. 19%) for the U.S. (all p<0.0001). The HCC proportion for both increased (SRTR peak 30% in 2015, SLTR 35% in 2016) then decreased. The most prominent trends for both were increases in ALD and decreases in CHC (trend p<0.0001). NASH/MASH also increased: SRTR 9% to 28%, ELTR 5% to 12%. From SRTR, NASH/MASH was the common etiology by 2022; ALD was the most common and fastest-growing in ELTR. In patients without HCC, the three most common etiologies were identical: ALD, NASH/MASH, primary sclerosing cholangitis. Predictors of higher post-transplant mortality included earlier calendar year, older recipient's age, male, higher MELD, grade III/IV encephalopathy, having CHC-HCC, older donor's age, small transplant center (all aHR>1.0, p<0.01), similar between ELTR and SRTR, in patients without and with HCC.

Conclusions: ALD and NASH/MASH are now leading indications for liver transplantation in two large global regions.