BACKGROUND: Lamellar keratoplasties have had a great impact in the management of corneal edema due to endothelial dysfunction. Minimally invasive transplant techniques such as Descemet Membrane Endothelial Keratoplasty (DMEK) have helped to reduce the morbidity involved in performing penetrating keratoplasty in this type of patient. Even so, these are complex techniques that are not free of complications and require a long line of surgical learning and an even more demanding experience in postoperative management.
METHODS: An 89-year-old woman suffering from Fuchs endothelial dystrophy and undergoing combined cataract and DMEK surgery presented stromal edema predominantly inferior and sectoral detachment of the graft 24 h after the intervention. After re-bubbling in consultations and 4 days later, the graft was observed rolled and free in the anterior chamber. She underwent re-DMEK with preservation of the original graft after 24 h, with de-epithelialization to optimize visualization. The graft was stained with trypan blue and the posterior stroma was protected with air. The graft was reimplanted under intraocular maneuvers and with an air bubble. 24 h after surgery, the adhered graft was observed, with a great decrease in stromal edema. One month later, the patient had a clear cornea, persistent complete graft adhesion, and visual acuity of 0.9.
CONCLUSIONS: The discovery of free roll in the anterior chamber after DMEK surgery constitutes the most complex form of graft detachment. Corneal edema as well as the arrangement of the different intraocular structures are conditions to be considered for the surgical resolution of this complication. In many cases, surgical repositioning of the graft is feasible, which means saving costs without the need to use new donor corneal tissues.

IgG replacement therapy (IgG-RT) has radically changed the clinical evolution of primary immunodeficiencies, yet the information regarding secondary hypogammaglobulinemia (SHG) is insufficient or conflicting. We aim to describe clinical features, evolution and treatment of SHG patients in our center.
Dynamic retrospective cohort between January 2001 and July 2021 of adults with gamma globulin fraction <0.6g/dL in a serum protein electrophoresis and a coincident decrease of IgG levels - with a disease-related SHG or treatment that reduces serum immunoglobulins.
We included 1012 patients with SHG with a median follow-up of 5 years (IQR 2-8). Hematological diseases were identified in 95% of the patients and 61% received drugs related to SHG. Sixty five percent had more than one etiological factor associated with SHG. Infectious diseases were present in 69% of the patients, 48% had respiratory infections and 17% had severe infections. There was statistical association between respiratory and severe infections with multiple myeloma (MM), lymphoma and rituximab. MGUS had less infections and death compared with other etiologies. IgG-RT was indicated in 18.7% of the patients and 4.6% received it for more than 6 months with variable intervals. Among the latter group, there was a significant reduction of all-type infections and respiratory infections with IgG-RT (p<0.001), and it was consistent with similar findings in lymphoma, MM and all IgG levels subgroups.
SHG was associated with more than one etiological factor and a high frequency of infections. IgG-RT indication was irregular yet still effective. It is relevant to consider IgG levels screening, monitoring and accurate indication of IgG-RT.

BACKGROUND: Graft-versus-host disease (GVHD) is a major complication after allogeneic hematopoietic stem cell transplantation.
OBJECTIVE: To elucidate the role of Toll-like receptor 4 (TLR4), the major receptor for bacterial lipopolysaccharide, in the development of GVHD, we constructed a GVHD model in TLR4 knockout (TLR4-/-) mice and monitored the cell chimerism.
METHODS: In this study, we used polymerase chain reaction to identify whether TLR4 knockout (TLR4-/-) mice were established. Before transplantation, we pretreated mice with irradiation so as to obtain an appropriate irradiation dose. Flow cytometry was applied to measure the chimerism status, the distributions of antigen-presenting cells (APCs), and T-cells in TLR4+/+ and TLR4-/- recipient mice.
RESULTS: The general condition of TLR4-/- recipients was better than that of TLR4+/+ recipients, and the TLR4-/- recipient mice showed less severe GVHD manifestations than the TLR4+/+ recipient mice. Most of the APCs and T-cells in the host mouse spleen were derived from donor cells, and CD4+ T-cells, including memory T-cells, were in the majority in host mice.
CONCLUSIONS: In general, our data show that TLR4 deletion attenuated GVHD development, which suggests that TLR4 could be used as a novel target and therapeutic paradigm in GVHD therapies.
BACKGROUND: La enfermedad de injerto contra huésped (EICH) es una complicación importante después del trasplante alogénico de células madre hematopoyéticas.
OBJECTIVE: Para dilucidar el papel de TLR4, el principal receptor de LPS bacteriano, en el desarrollo de GVHD, construimos un modelo de GVHD en ratones knockout para TLR4 (TLR4-/-) y monitoreamos el quimerismo celular.
UNASSIGNED: En este estudio, usamos PCR para identificar si se establecieron ratones knockout para TLR4 (TLR4-/-). Antes del trasplante, pretratamos a los ratones con irradiación para obtener la dosis de irradiación adecuada. Se aplicó citometría de flujo para medir el estado de quimerismo, las distribuciones de APC y células T en ratones receptores TLR4+/+ y TLR4-/-.
RESULTS: El estado general de los receptores de TLR4-/- fue mejor que el de los receptores de TLR4+/+, y los ratones receptores de TLR4-/- mostraron manifestaciones de GVHD menos graves que los ratones receptores de TLR4+/+. La mayoría de las APC y las células T en el bazo del ratón huésped se derivaron de las células del donante, y las células T CD4+, incluidas las células T de memoria, se encontraban en su mayoría en los ratones huéspedes.
UNASSIGNED: En general, nuestros datos muestran que la eliminación de TLR4 atenuó el desarrollo de GVHD, lo que sugiere que TLR4 podría usarse como un nuevo objetivo y paradigma terapéutico en las terapias de GVHD.

Passenger lymphocyte syndrome (PLS) causes immune-mediated hemolysis in solid and bone marrow transplant recipients. Donor-derived antibodies against the recipient erythrocyte drive the pathogenesis. It is a rare entity in kidney transplantation, and most of the cases are self-limited.
A 36-year-old woman presented with fatigue 13 days after living donor renal transplantation. The operation was uneventful, and she was discharged with normal graft functions on the 11th day of transplantation Findings were consistent with cold agglutinin disease at her admission. However, the cold agglutinin test was negative. Eventually, she was diagnosed with PLS. Refractory intravascular hemolysis and frank hemoglobinuria were also present in the patient. Hemolysis was resistant to steroids, intravenous immunoglobulin (IVIG), and Rituximab. Because of life-threatening anemia related to refractory PLS, mycophenolate and tacrolimus were interrupted. However, hemolysis persisted. Following that, immunoadsorption (IA) treatment was obtained. Unfortunately, graft loss occurred due to rejection despite the resolution of PLS after IA.
PLS is a rare and usually self-limited entity. Our case was an atypical refractory PLS that resembled cold agglutinin disease. Also, frank hemoglobinuria was observed related to severe intravascular hemolysis. These features have not been described before in PLS, to the best of our knowledge. Additionally, IA treatment had never been reported in the literature for PLS, as far as we know. Treatment and management could be a challenge in refractory PLS. Rituximab, IVIG, and extracorporeal treatments could be beneficial. It should be borne in mind that refractory PLS can cause graft and patient loss.

Advancements in the field of reintroduction biology are needed, but understanding of how to effectively conduct translocations, particularly with snakes, is lacking. We conducted a systematic review of snake translocation studies to identify potential tactics for reducing postrelease effects. We included studies on intentional, human-mediated, wild-wild, or captive-wild translocations to any location, regardless of motive or number of snakes translocated. Only studies that presented results for at least 1 of 4 outcomes (movement behavior, site fidelity, survival, or population establishment) were included. We systematically searched 4 databases for published studies and used 5 methods to search the gray literature. Our search and screening criteria yielded 121 data sources, representing 130 translocation cases. We quantified the association between 15 translocation tactics and short-term translocation outcomes by calculating odds ratios and used forest plots to display results. Snake translocations involved 47 species (from mainly 2 families), and most were motivated by research, were monitored for at least 6 months, occurred in North America, and took place from the 1990s onward. The odds of a positive snake translocation outcome were highest with release of captive reared or juvenile snakes, release of social groups together, delayed release, provision of environmental enrichment or social housing before release, or minimization of distance translocated. The odds of a positive outcome were lowest when snakes were released early in their active season. Our results do not demonstrate causation, but outcomes of snake translocation were associated with 8 tactics (4 of which were strongly correlated). In addition to targeted comparative studies, we recommend practitioners consider the possible influence of these tactics when planning snake translocations.
La biología de la reintroducción requiere de avances; sin embargo, hay muy poco conocimiento sobre cómo realizar efectivamente las reubicaciones, particularmente las de las serpientes. Revisamos sistemáticamente los estudios sobre reubicación de serpientes para identificar las potenciales maniobras de reducción del estrés postliberación. Incluimos estudios sobre las reubicaciones a cualquier localidad que hayan sido intencionales, mediadas por humanos, de ambiente silvestre a ambiente silvestre o de cautiverio a ambiente silvestre sin importar el motivo o el número de serpientes reubicadas. Sólo incluimos estudios que presentaran resultados para al menos 1 de los cuatro resultados posibles: conducta de movimiento, fidelidad al sitio, supervivencia o establecimiento poblacional. Buscamos sistemáticamente en cuatro bases de datos de estudios publicados y usamos cinco métodos para buscar en la literatura gris. Nuestros criterios de búsqueda y revisión resultaron en 121 fuentes de datos, las cuales representaron 130 casos de reubicación. Cuantificamos la asociación entre 15 maniobras de reubicación y los resultados a corto plazo de las reubicaciones mediante el cálculo de la razón de probabilidades y usamos diagramas de efecto para mostrar los resultados. La reubicación de serpientes incluyó a 47 especies (principalmente de dos familias) y la mayoría estuvo motivada por la investigación, fue monitoreada durante seis meses (al menos), se ubicó en América del Norte y ocurrieron a partir de la década de 1990. La probabilidad de que la reubicación de serpientes tuviera un resultado positivo fueron mayores con la liberación de serpientes criadas o juveniles, la liberación de grupos sociales en conjunto, la liberación retardada, el suministro de enriquecimiento ambiental o alojamiento previo a la liberación o la reducción de la distancia de reubicación. Esta misma probabilidad fue menor cuando las serpientes fueron liberadas tempranamente durante su temporada activa. Nuestros resultados no demuestran causalidad, pero los resultados de la reubicación de serpientes estuvieron asociados con ocho maniobras (cuatro de las cuales contaban con una correlación sólida). Además de los estudios comparativos focalizados, recomendamos que los practicantes consideren la posible influencia de estas maniobras cuando se planifiquen la reubicación de serpientes.
重引入领域需要进一步发展, 但如何有效进行生物迁移仍存在知识空缺, 特别是对蛇类的迁移。我们对蛇类迁地研究进行了系统性综述, 以确定减少释放后影响的潜在策略。我们收集了所有地区有意的、人类介导的、野生-野生及圈养-野生的迁地研究, 无论动机或蛇的数量。只有包含四个结果(运动行为、位点保守性、存活率、种群建立情况)中至少一个的研究才被纳入分析。我们系统地搜索了四个数据库中已发表的研究, 并用五种方法搜索了灰色文献, 最终获得121个数据源, 代表了130个迁地案例。我们通过计算优势比量化了15种迁地策略和短期迁地结果之间的关联, 并用森林图展示了结果。我们发现, 蛇类的迁移涉及47个物种(主要来自2个科), 大多数发生在北美、在20世纪90年代以后、出于研究的动机, 且监测了至少6个月。在释放人工饲养的蛇或亚成体蛇、同时释放社会群体、延迟释放、在释放前提供环境丰容或遮蔽物, 以及尽量减少迁移距离的情况下, 产生积极结果的几率最高。当在蛇的活动季节早期释放, 产生积极结果的几率最低。我们的结果并不能证明因果关系, 但发现蛇类迁移结果与8种策略有关(其中4种强相关)。除了有针对性的比较研究外, 我们还建议保护实践者在规划蛇类迁地项目时考虑这些策略可能产生的影响。【翻译:胡怡思;审校:聂永刚】.

Prevalence of hypertension increases as glomerular filtration rate (GFR) declines. Renalase metabolizes catecholamines and have an important role in blood pressure (BP) regulation. The purpose of the study was to evaluate the effect of kidney transplantation on renalase levels and BP in kidney donors and recipients.
Twenty kidney transplant recipients and their donors were included in the study. Serum renalase levels and ambulatory BP values were measured in both donors and recipients before and after transplantation. Factor associated with change in renalase and BP levels were also evaluated.
In donors; mean GFR and hemoglobin levels decreased while night-time systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels and serum renalase levels increased simultaneously after nephrectomy. Day-time SBP and DBP levels did not changed and the night/day ratio of mean arterial pressure (MAP) increased significantly. In recipients, mean GFR increased, while mean serum renalase levels, creatinine and BP levels decreased after transplantation. Correlation analysis revealed that changes in MAP correlated with alteration in serum renalase levels and GFR.
After transplantation, serum renalase levels increased in donors and decreased in recipients. The renalase levels are associated with change in MAP and circadian rhythm of BP in donors and recipients.

OBJECTIVE: Orthotopic liver transplant (OLT) is the definitive treatment of most types of liver failure. Transjugular intrahepatic portosystemic shunt (TIPS) and portocaval shunt placement procedures reduce the systemic vascular complications of portal hypertension. TIPS placement remains a \"bridge\" therapy that enables treatment of refractory symptoms until transplantation becomes available. The aim of the present study was to describe the operative impact of TIPS prior to OLT.
METHODS: A retrospective review was conducted on patients that underwent liver transplant at the Hospital San José within the timeframe of 1999 and February 2020.
RESULTS: We reviewed a total of 92 patients with OLT. Sixty-six patients were male and 26 were female, with a mean age of 52 years. Nine (9.8%) of the 92 patients had a TIPS, before the OLT. Preoperative Child-Pugh class, MELD score, and sodium and platelet levels were similar between groups. We found no difference in the means of intensive care unit stay, operative time, or blood transfusions for liver transplant, with or without previous TIPS. There was no significant difference between groups regarding vascular and biliary complication rates or the need for early intervention. The overall one-year mortality rate in the TIPS group was 11%.
CONCLUSIONS: TIPS is an appropriate therapeutic bridge towards liver transplant. We found no greater operative or postoperative complications in patients with TIPS before OLT, when compared with OLT patients without TIPS. The need for transfusion, operative time, and ICU stay were similar in both groups.

Hepatocellular carcinoma (HCC) is more frequently manifesting as one of the main complications of cirrhosis of the liver, its principal risk factor. There have been modifications in its incidence over the past decade, related to an epidemiologic transition in the etiology of cirrhosis, with a decrease in the prevalence of hepatitis C and an increase in nonalcoholic fatty liver disease (NAFLD) as a cause, as well as the development of HCC in the non-cirrhotic liver due to NAFLD. Genetic markers associated with the disease have been identified, and surveillance and diagnosis have improved. Regarding treatment, surgical techniques, in both resection and transplantation, have advanced and radiologic techniques, at the curative stage of the disease, have enhanced survival in those patients. And finally, there have been radical changes in the systemic approach, with much more optimistic expectations, when compared with the options available a decade ago. Therefore, the Asociación Mexicana de Hepatología decided to carry out the Second Mexican Consensus on Hepatocellular Carcinoma, which is an updated review of the available national and international evidence on the epidemiology, risk factors, surveillance, diagnosis, and treatment of the disease, to offer the Mexican physician current information on the different topics regarding hepatocellular carcinoma. In this second part of the document, the topics related to the treatment of HCC are presented.

Complications arising from ureterovesical anastomosis in kidney transplantation have an important influence on the success of the procedure. The most serious and frequent complications are fistula and stenosis of the ureterovesical junction. The placement of double J stents in anastomosis is currently recommended to reduce these complications.
The aim of the study is to evaluate whether the placement of a DJ stent affects complications of anastomosis.
Retrospective analysis of 697 patients treated with cadaveric donor renal transplant in our center from 1999 to 2018 was performed. Results were compared according to double J stent placement and the surgical technique employed for anastomosis.
Transplantation was performed without DJ placement in 51.7% of the patients, compared to 48.3% who were treated with DJ stent placement. The most commonly used technique was Lich-Gregoir. Ureterovesical fistula occurred in 5% of cases, and ureterovesical stenosis in 4.2%. DJ stent behaved as a protective factor for ureterovesical fistula but did not significantly influence the development of stenosis. The Taguchi technique greatly increased the risk of developing both ureterovesical fistula and stenosis. The incidence of stenosis and fistula was significantly higher when the Taguchi technique was combined with no DJ stent placement.
DJ stent placement acts as a protective factor for ureterovesical stenosis complications. The results of our study seem to agree with current literature.

OBJECTIVE: To identify the available information to support registered nurses\' clinical decisions in assessing and validating potential organ and tissue donors during the COVID-19 pandemic.
METHODS: This is a scoping review developed in six stages. The sixth stage was developed with registered nurses who work in the Brazil Organ Donation System. To consolidate the information and prepare all assumptions, the legislation in force in Brazil was followed.
RESULTS: Recommendations from 19 articles identified in the literature were analyzed; additionally, 52 professionals who work at Brazil Organ Donation System participated in the research. Four care assumptions were formed: investigation of community transmission, investigation of clinical situations, screening for COVID-19 signs and symptoms, and investigation of alterations presented in the physical examination. Such assumptions are formed by 34 care guidelines.
CONCLUSIONS: Care assumptions were prepared to guide and support registered nurses during assessment and validation of potential organ and tissue donors. From this perspective, assumptions certainly promote safety, effectiveness and quality in the service offered during the organ and tissue donation process in the midst of the COVID-19 pandemic, in addition to empowering registered nurses in this scenario. Quality and bio-surveillance through the donation stages have been discussed extensively in recent times, to improve donation and transplantations by valuing care, safety, and quality of life of recipients.
CONCLUSIONS: The care assumptions presented in this study support and subsidize the daily practice of registered nurses who work in assessing and validating potential organ and tissue donors, enabling these professionals to make decisions based on secure information.