Direct-acting Antivirals for the Treatment of Kidney Transplant Patients With Chronic Hepatitis C Virus Infection in Spain: A Long-term Prospective Observational Study Background. Direct-acting antivirals (DAA) allow effective and safe eradication of hepatitis C virus (HCV) in most patients. There are limited data on the long-term effects of all-oral, interferon-free DAA combination therapies in kidney transplant (KT) patients infected with HCV. Here we evaluated the long-term tolerability, efficacy, and safety of DAA combination therapies in KT patients with chronic HCV infection. Methods. Clinical data from KT patients treated with DAA were collected before, during, and after the treatment, including viral response, immunosuppression regimens, and kidney and liver function. Results. Patients (N = 226) were mostly male (65.9%) aged 56.1 ± 10.9 years, with a median time from KT to initiation of DAA therapy of 12.7 years and HCV genotype 1b (64.6%). Most patients were treated with sofosbuvir-based therapies. Rapid virological response at 1 month was achieved by 89.4% of the patients and sustained virological response by week 12 by 98.1%. Liver function improved significantly after DAA treatment. Tacrolimus dosage increased 37% from the beginning of treatment (2.5 ± 1.7 mg/d) to 1 year after the start of DAA treatment (3.4 ± 1.9 mg/d, P < 0.001). Median follow-up was 37.0 months (interquartile range, 28.4–41.9) and death-censored graft survival was 91.1%. Adverse events resulting from DAA treatment, especially anemia, were reported for 31.0% of the patients. Conclusions. Chronic HCV infection can be treated efficiently and safely with DAA therapy in KT patients. Most patients retained stable kidney function and improved liver function. Tacrolimus dose had to be increased in most patients, potentially as a result of better liver function. Published online 18 November, 2019. Received 2 October 2019. Accepted 6 October 2019. All authors participated in research design and contributed with data from their respective hospitals. J.C.R. collected data and performed the initial data analysis. All authors provided feedback on the data results. J.C.R. wrote draft of the manuscript and all authors contributed to and approved the final version. The authors declare no conflicts of interest. This work was partially supported by a grant from the Instituto de Salud Carlos III co-funded by the Fondo Europeo de Desarrollo Regional-FEDER, RETICS (REDinREN RD16/0009). Astellas Pharma S.A. provided financial support for medical writing and editing of the manuscript. Correspondence: Juan Carlos Ruiz, MD, Department of Nephrology, Hospital Marqués de Valdecilla, Av. Valdecilla, 25, 39008 Santander, Cantabria, Spain. (ruizjc@humv.es). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Kidney Donor Profile Index Is a Reliable Alternative to Liver Donor Risk Index in Quantifying Graft Quality in Liver Transplantation Background. The most established metric for estimating graft survival from donor characteristics in liver transplantation is the liver donor risk index (LDRI). The LDRI is calculated from donor and transplant-related variables, including cold ischemic time. Because cold ischemic time is unknown at the time of organ offer, LDRI is not available for organ acceptance decisions. In contrast, the kidney donor profile index (KDPI) is derived purely from donor variables known at the time of offer and thus calculated for every deceased donor in the United States. The similarity in donor factors included in LDRI and KDPI led us to hypothesize that KDPI would reliably approximate LDRI in estimating graft survival in liver transplantation. Methods. The United Network of Organ Sharing registry was queried for adults who underwent deceased donor liver transplantation from 2002 to 2016. The cohort was divided into quintiles of KDPI and LDRI, and graft survival was calculated according to Kaplan Meier. Hazard ratios for LDRI and KDPI were estimated from Cox proportional hazards models, and Uno’s concordance statistic was compared. Results. In our analysis of 63 906 cases, KDPI closely approximated LDRI in estimating liver graft survival, with an equivalent concordance statistic of 0.56. Conclusions. We conclude that KDPI can serve as a reasonable alternative to LDRI in liver acceptance decisions. Published online 25 November, 2019. Received 2 July 2019. Revision received 21 September 2019. Accepted 15 October 2019. U.S. contributed to research design, writing, performance of research, and data analysis. T.T. contributed to research design, data analysis, and critical review. E.R.S. contributed to data analysis and critical review. K.F. contributed to data analysis and critical review. Q.G. contributed to data analysis and critical review. J.Y. contributed to data analysis and critical review. B.E. contributed to data analysis and critical review. R.P.D. contributed to data analysis and critical review. P.M.S. contributed to data analysis and critical review. S.B.P. contributed to research design, data analysis, and critical review. A.S.B. contributed to research design, writing, data analysis, and critical review. The authors declare no funding or conflicts of interest. Correspondence: Andrew S. Barbas, MD, DUMC Box 3512, Durham, NC 27710. (andrew.barbas@duke.edu). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Public Solicitation and The Canadian Media: Two Cases of Living Liver Donation, Two Different Stories Background . Two stories of public solicitation for living liver donors received substantial Canadian media attention in 2015: The Wagner family, with twin toddlers, each needing transplants, and Eugene Melnyk, wealthy owner of a professional hockey team. This study compared the print media coverage of these 2 stories to understand how public solicitation was portrayed and whether coverage differed depending on the individual making the plea. Methods. We conducted a content analysis on 155 relevant Canadian newspaper articles published between January 1, 2015 and December 31, 2016. Articles were analyzed for their description of public solicitation, benefits and issues associated with public solicitation, and overall tone with respect to public solicitation. Results. The foregrounding of public solicitation and associated ethical issues featured heavily in articles focused on Melnyk but were largely absent when discussing the Wagner family. The fairness of Melnyk's solicitation was the most prominent ethical issue raised. Laws and policies surrounding public solicitation also featured in the Melnyk story but not in articles focused on the Wagners. Public solicitation was portrayed more negatively in the Melnyk articles, but overall, was portrayed positively in relation to both Melnyk and the Wagner family. Conclusions. Public solicitation was generally portrayed as a positive phenomenon in Canadian print media, yet there were stark differences in how these cases were presented. The Wagner story was largely portrayed as a human-interest piece about a family in dire circumstances, whereas Melnyk's wealth, status, and influence raised questions of the fairness of his transplant. Published online 15 November, 2019. Received 4 September 2019. Revision received 18 September 2019. Accepted 19 September 2019. Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.transplantationdirect.com). Supported by Genome Canada and Genome Alberta: Precision Medicine Applying Precision Medicine Technologies in Canada to Prevent Antibody Mediated Rejection and Premature Kidney Transplant Loss (CanPREVENT AMR) and Canadian Institutes of Health Research and the Kidney Foundation of Canada: The Canadian National Transplant Research Program: Increasing Donation and Improving Transplantation Outcomes. A.R.M., M.T., T.C. designed the study. A.R.M. compiled and analyzed the data with assistance from M.T., A.R.M., and M.T. wrote the initial drafts of the article. A.R.M., M.T., and T.C. edited, revised, and contributed to the final version of the article. The authors declare no conflicts of interest. Correspondence: Maeghan Toews, LLM, Adelaide Law School Room 2.05 Ligertwood Bldg University of Adelaide, N Trc Adelaide SA 5005, Australia. (maeghan.toews@adelaide.edu.au). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Whole Body CT Imaging in Deceased Donor Screening for Malignancies Background. In most western countries, the median donor age is increasing. The incidence of malignancies in older populations is increasing as well. To prevent donor-derived malignancies we evaluated radiologic donor screening in a retrospective donor cohort. Methods. This study analyzes the efficacy of a preoperative computed tomography (CT) scan on detecting malignancies. All deceased organ donors in the Netherlands between January 2013 and December 2017 were included. Donor reports were analyzed to identify malignancies detected before or during organ procurement. Findings between donor screening with or without CT-scan were compared. Results. Chest or abdominal CT-scans were performed in 17% and 18% of the 1644 reported donors respectively. Screening by chest CT-scan versus radiograph resulted in 1.5% and 0.0% detected thoracic malignancies respectively. During procurement no thoracic malignancies were found in patients screened by chest CT compared with 0.2% malignancies in the radiograph group. Screening by abdominal CT-scan resulted in 0.0% malignancies, compared with 0.2% in the abdominal ultrasound group. During procurement 1.0% and 1.3% malignancies were found in the abdominal CT-scan and ultrasound groups, respectively. Conclusions. Screening by CT-scan decreased the perioperative detection of tumors by 30%. A preoperative CT-scan may be helpful by providing additional information on (aberrant) anatomy to the procuring or transplanting surgeon. In conclusion, donor screening by CT-scan could decrease the risk of donor-derived malignancies and prevents unnecessary procurements per year in the Netherlands. Published online 15 November, 2019. Received 5 September 2019. Accepted 29 September 2019. The authors declare no funding or conflicts of interest. Author contributions A.E.B., I.P.J.A., and J.W.M. participated in research design. J.W.M. participated in data collection. A.E.B., R.A.P., and J.W.M. participated in data analysis. All authors participated in construction and critical revision of the article. Correspondence: J.W. Mensink, MD, Department of Surgery, Division of Transplantation, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands. (j.w.mensink@hotmail.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Comparison of a Behavioral Versus an Educational Weight Management Intervention After Renal Transplantation: A Randomized Controlled Trial Background. In the first year following renal transplantation, preventing weight gain to minimize overweight or obesity is particularly important. The aim of this study is to test the effect of an 8-month behavioral intervention BMI and physical activity. Methods. This randomized controlled study included 123 adult kidney or kidney-pancreas recipients. Patients were randomized to usual (1 educational session, then weight self-monitoring) and intervention care (usual care plus 7–8 counseling sessions). Alongside weight, body composition, and physical activity, satisfaction and perceptions regarding care were measured at weeks 2–6 (baseline), then at months 8 and 12. Results. Both groups reported comparably high satisfaction. The intervention group (IG) reported more chronic care-related activities. In patients with BMIs ≥ 18.5, mean weight gain (from baseline) was unexpectedly low in both groups: at month 8, +0.04 kg/m2 in IG patients and +0.14 kg/m2 in the control group (P = 0.590), and respectively, +0.03 kg/m2 and +0.19 kg/m2 at month 12 (P = 0.454). Both groups were physically active, walking averages of 10 807 (IG) and 11 093 (control group) steps per day at month 8 (P = 0.823), and respectively 9773 and 11 217 at month 12 (P = 0.195). Conclusions. The behavioral intervention had high patient acceptance and supported patients in maintaining their weight, but had no superior effect on a single educational session. Further research is needed to assess patient weight gain risk profiles to stratify the intervention. Published online 15 November, 2019. Received 5 July 2019. Accepted 26 July 2019. Trial registration number: NCT02282124 (ClinicalTrials.gov) G.S-M. performed the writing of the article, designing the study, and study management. P.Z. performed the co-writing of the article and development and provision of the intervention. N.G. performed the co-writing of the article and statistical analysis. P.W. performed the co-designing and implementation of intervention in clinical practice and critical revision of article. T.F.M. performed the critical revision of article R.W. performed the implementation of study in clinical practice. L.H. performed the data management. T.F. is the second senior author and performed the co-designing of the study and intervention and critical revision of article. R.S. performed the co-designing of the study and the intervention and critical revision of article. T.F. and R.S. are both senior author. The authors declare no conflicts of interest. Supported by an unrestricted grant from Astellas Pharma Switzerland, Novartis Pharma Switzerland, and the Béatrice Ederer-Weber Stiftung Switzerland. Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.transplantationdirect.com). Correspondence: Gabriela Schmid-Mohler, PhD, RN, Center of Clinical Nursing Science, University Hospital Zurich, Ramistrasse 100, CH-8091 Zurich, Switzerland. (gabriela.schmid@usz.ch). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Insights Into the Experience of Liver Transplant Recipients With Alcoholic Liver Disease: A Descriptive Qualitative Study Background. Alcoholic liver disease (ALD) due to alcohol use disorder (AUD) is the primary cause of liver transplantation (LT) in the United States. Studies have found that LT recipients experience a range of physical and emotional difficulties posttransplantation including return to alcohol use, depression, and anxiety. The aim of this study is to better understand the experiences of LT recipients with ALD because they recovered posttransplant to inform the development of a patient-centered intervention to assist patients during recovery. Methods. Using qualitative methods, researchers conducted semi-structured interviews with 16 ALD LT recipients. The primary topics of the interview were physical recovery, mental health, substance use including alcohol and tobacco use, and financial experiences. Common patient themes were identified and coded. Results. Within the domain of physical health, patients stressed that undergoing LT was a near-death experience, they were helpless, changes in weight influenced their perception of their illness, and they have ongoing medical problems. In the domain of mental health, patients described cognitive impairments during their initial recovery, difficulty in processing the emotions of having a terminal condition, ongoing depression, anxiety, and irritability. The patients also described their perception of having AUD, the last time they used alcohol and their attitude to AUD treatment posttransplant. Patients also described their reliance on one member of their social support network for practical assistance during their recovery and identified one member of their medical team as being of particular importance in providing emotional as well as medical support during recovery. Conclusions. The patient’s description of their lived experience during the months following transplant informed the development of a patient-centered intervention that colocates behavioral health components with medical treatment that helps broaden their social network while addressing topics that emerged from this study. Published online 15 November, 2019. Received 29 January 2019. Revision received 20 September 2019. Accepted 21 September 2019. The authors declare no conflicts of interest. This work was supported by Agency for Healthcare Research and Quality #5R24HS022135-04/PI. M.H. conducted interviews and participated in creating coding scheme, coding transcripts, and writing the preliminary draft of the article. M.L.M. participated in research design and creating coding scheme, conducted interviews, participated in coding transcripts, and contributed to major editing of the draft. M.T. and J.L.M. and M.C. participated in research design, reviewed coding scheme, and reviewed and edited the article. P.S. conceptualized the study and provided oversight of research design, participated in creating coding scheme and writing preliminary draft of the article, and reviewed and substantially edited the final article. Correspondence: Martin Hochheimer, MSW, University of Maryland School of Social Work, 525 W Redwood St, Baltimore, MD 21201. (mhochheimer@ssw.umaryland.edu). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Evaluation of Intrahepatic Lactate/Pyruvate Ratio As a Marker for Ischemic Complications Early After Liver Transplantation—A Clinical Study Background. Lactate/pyruvate ratio has been introduced as a sensitive marker for ischemia in the transplanted liver. In the present study, we aimed to evaluate lactate/pyruvate ratio measured in the liver by microdialysis as a marker for ischemic complications early after liver transplantation. Methods. Forty-five patients undergoing liver transplantation were included in the study. A microdialysis catheter was placed in the liver graft directly following liver transplantation and the metabolites lactate and pyruvate measured for up to 6 days and the lactate/pyruvate ratio calculated. The association between increased intrahepatic lactate/pyruvate ratio and ischemic complications was studied. Results. One of 45 patients developed hepatic arterial thrombosis. Forty-four events with increased lactate/pyruvate ratio were identified in 24 patients. In none of the 24 patients that had a raised lactate/pyruvate ratio could we detect occurrence of any ischemic complication. In the patient that did have hepatic arterial thrombosis, the lactate/pyruvate ratio did not show a significant prolonged rise. Conclusions. An increase in the intrahepatic lactate/pyruvate ratio is not necessarily indicative of ischemic complications and is thus not a reliable marker for monitoring of clinically significant ischemia in the liver early after transplantation. Published online 15 November, 2019. Received 7 June 2016. Revision received 16 September 2019. Accepted 25 September 2019. A.v.P. involved in collection and analyzing of data and writing article. M.A.D.S. involved in analyzing of data and writing article. O.R. involved in writing article. G.N. involved in study design, collection and analyzing of data, and writing article This work was supported by CMA Microdialysis AB, Stockholm, Sweden. Pregraduate School of Clinical Science, Karolinska Institute. The authors declare no conflicts of interest. Correspondence: Anna von Platen, MD, Division of Transplantation Surgery, CLINTEC, Karolinska Institute, Karolinska University Hospital Huddinge F82, 141 86 Stockholm, Sweden. (annavonplaten@sll.se). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.