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Nath KA, Singh RD, Croatt AJ, Adams CM. Heme Proteins and Kidney Injury: Beyond Rhabdomyolysis. KIDNEY360 2022; 3:1969-1979. [PMID: 36514409 PMCID: PMC9717624 DOI: 10.34067/kid.0005442022] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/23/2022] [Indexed: 11/07/2022]
Abstract
Heme proteins, the stuff of life, represent an ingenious biologic strategy that capitalizes on the biochemical versatility of heme, and yet is one that avoids the inherent risks to cellular vitality posed by unfettered and promiscuously reactive heme. Heme proteins, however, may be a double-edged sword because they can damage the kidney in certain settings. Although such injury is often viewed mainly within the context of rhabdomyolysis and the nephrotoxicity of myoglobin, an increasing literature now attests to the fact that involvement of heme proteins in renal injury ranges well beyond the confines of this single disease (and its analog, hemolysis); indeed, through the release of the defining heme motif, destabilization of intracellular heme proteins may be a common pathway for acute kidney injury, in general, and irrespective of the underlying insult. This brief review outlines current understanding regarding processes underlying such heme protein-induced acute kidney injury (AKI) and chronic kidney disease (CKD). Topics covered include, among others, the basis for renal injury after the exposure of the kidney to and its incorporation of myoglobin and hemoglobin; auto-oxidation of myoglobin and hemoglobin; destabilization of heme proteins and the release of heme; heme/iron/oxidant pathways of renal injury; generation of reactive oxygen species and reactive nitrogen species by NOX, iNOS, and myeloperoxidase; and the role of circulating cell-free hemoglobin in AKI and CKD. Also covered are the characteristics of the kidney that render this organ uniquely vulnerable to injury after myolysis and hemolysis, and pathobiologic effects emanating from free, labile heme. Mechanisms that defend against the toxicity of heme proteins are discussed, and the review concludes by outlining the therapeutic strategies that have arisen from current understanding of mechanisms of renal injury caused by heme proteins and how such mechanisms may be interrupted.
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Affiliation(s)
- Karl A. Nath
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Raman Deep Singh
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anthony J. Croatt
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher M. Adams
- Division of Endocrinology, Metabolism and Nutrition, Department of Medicine, Mayo Clinic Rochester, Minnesota
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Laitselart P, Derely J, Daban JL, De Rudnicki S, Libert N. Relationship between creatine kinase and liver enzymes in war wounded with rhabdomyolysis. Injury 2022; 53:166-170. [PMID: 34689987 DOI: 10.1016/j.injury.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/15/2021] [Accepted: 10/06/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Rhabdomyolysis is a frequent complication in war wounded. Its complex pathophysiology suggests that it not only affects kidneys but also other organs such as the liver. The aim of this study was to evaluate the relationship between creatine kinase (CK) and liver enzymes in war wounded with rhabdomyolysis. METHODS War wounded admitted to the intensive care unit of Percy Military Hospital between 2009 and 2017 with a rhabdomyolysis (CK peak >1,000 U/L) were included. They were divided in two groups: mild (CK peak <10,000 U/L) and severe rhabdomyolysis (CK peak ≥10,000 U/L). Demographic characteristics, peaks in transaminases, alkaline phosphatase (ALP), bilirubin, and CK were recorded. Mann Whitney-U test and, Fisher's exact test were used as appropriate. A Pearson's correlation test was used to determine the correlation between CK and liver enzymes after a log-normal transformation of the data. RESULTS Fifty-one patients were included (31 in the mild and 20 in the severe rhabdomyolysis group). Patients in the severe rhabdomyolysis group were more likely victims of explosions (85% vs 39%, p = 0.003). The transaminases peak was significantly higher in the severe rhabdomyolysis group (median AST peak 398 (270-944) vs 91 (63-157) U/L, p <0.0001, and median ALT peak 106 (77-235) vs 45 (34-71) U/L, p<0.0001). Bilirubin and ALP were higher in the severe rhabdomyolysis group (39 (25-49) vs 14(11-23) U/L, p = 0.0031 and 84 (55-170) vs 52 (39-85) U/L, p = 0.0063, respectively). We found a significant positive linear correlation between CK and ALT (r = 0.73, p<0.0001), AST (r = 0.89, p<0.0001), ALP (r = 0.41, p = 0.0035), and bilirubin (r = 0.37, p = 0.0083). CONCLUSION We found a statistically significant positive correlation between CK and liver enzymes in rhabdomyolysis war wounded, indicating that hepatic damage occurs when rhabdomyolysis is severe and associated with elevated bilirubin and ALP. Further studies are needed to confirm this phenomenon and elucidate the pathophysiological mechanism. LEVEL OF EVIDENCE IV STUDY TYPE: Diagnostic.
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Affiliation(s)
- Philippe Laitselart
- Percy Military Teaching Hospital, Department of Anesthesiology and intensive care unit, 101 avenue Henri Barbusse, 92140 Clamart, France.
| | - Jean Derely
- Percy Military Teaching Hospital, Department of Anesthesiology and intensive care unit, 101 avenue Henri Barbusse, 92140 Clamart, France
| | - Jean-Louis Daban
- Percy Military Teaching Hospital, Department of Anesthesiology and intensive care unit, 101 avenue Henri Barbusse, 92140 Clamart, France
| | - Stéphane De Rudnicki
- Percy Military Teaching Hospital, Department of Anesthesiology and intensive care unit, 101 avenue Henri Barbusse, 92140 Clamart, France
| | - Nicolas Libert
- Percy Military Teaching Hospital, Department of Anesthesiology and intensive care unit, 101 avenue Henri Barbusse, 92140 Clamart, France
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Lubbe C, Harvey BH, Viljoen FP, Meyer L, Wolmarans DW. Forced running-induced rhabdomyolysis in the Sprague-Dawley rat: towards a rodent model of capture myopathy. Vet Res Commun 2021; 45:459-465. [PMID: 34570329 DOI: 10.1007/s11259-021-09840-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/23/2021] [Indexed: 01/04/2023]
Abstract
Capture myopathy (CM) is a metabolic disease associated with mortality in mass boma captured (MBC) wildlife. The condition is induced by the forced pursuit, capturing, and restraint of wild animals, although its causal biology remains to be confirmed. A core feature of MBC-CM is rhabdomyolysis, which is associated with myoglobinuria and hyperthermia. Towards developing a translational model of CM-associated rhabdomyolysis, we investigated forced treadmill running to induce physical exhaustion and trigger rhabdomyolysis in Sprague Dawley (SD) rats. Twenty-four (24) SD rats (12 per sex) were subjected to treadmill habituation in a speed-tiered approach. Forty-eight hours after the last habituation session, one strenuous exercise (SE) session was performed at 75% of the theoretical VO2MAX (30 m/min) until animals reached physical exhaustion. Core and skin surface temperatures were measured before the SE session and after rats reached exhaustion, after which a 1-h-cumulative urine sample was collected, and the myoglobin content assayed. We show that most SE, but not control-exposed (non-exercise) rats presented with myoglobinuria, while core and surface body temperatures in both male and female rats were significantly higher post-exercise. This pre-clinical model framework shows potential for investigating the pathophysiology of MBC-CM.
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Affiliation(s)
- Crystal Lubbe
- Center of Excellence for Pharmaceutical Sciences and North-West University, Potchefstroom, South Africa
| | - Brian H Harvey
- Center of Excellence for Pharmaceutical Sciences and North-West University, Potchefstroom, South Africa
- MRC Unit On Risk and Resilience in Mental Disorders, Department of Psychiatry and Mental Health and Neuroscience Institute, Cape Town, South Africa
| | - Francois P Viljoen
- Center of Excellence for Pharmaceutical Sciences and North-West University, Potchefstroom, South Africa
| | - Leith Meyer
- Department of Paraclinical Sciences and Center for Veterinary Wildlife Research, University of Pretoria, Pretoria, South Africa
| | - De Wet Wolmarans
- Center of Excellence for Pharmaceutical Sciences and North-West University, Potchefstroom, South Africa.
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Tarazona V, Figueiredo S, Hamada S, Pochard J, Haines RW, Prowle JR, Duranteau J, Vigué B, Harrois A. Admission serum myoglobin and the development of acute kidney injury after major trauma. Ann Intensive Care 2021; 11:140. [PMID: 34559325 PMCID: PMC8463647 DOI: 10.1186/s13613-021-00924-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 09/06/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Myoglobin and creatine kinase (CK) are both established markers of muscle injury but their hospital admission values have never been compared to predict post-traumatic acute kidney injury (AKI). METHODS An observational registry study of consecutive trauma patients admitted to a major regional trauma centre. The primary outcome was stage 1 or more AKI in the first 7 days after trauma. We assessed the association of hospital admission myoglobin or CK with development of AKI both alone and when added to two existing risk prediction models for post traumatic AKI. RESULTS Of the 857 trauma patients (median age 36 [25-52], 96% blunt trauma, median ISS of 20 [12-47]) included, 102 (12%) developed AKI. Admission myoglobin performed better than CK to predict AKI any stage with an AUC-ROC of 0.74 (95% CI 0.68-0.79) and 0.63 (95% CI 0.57-0.69), respectively (p < 0.001). Admission myoglobin also performed better than CK to predict AKI stage 2 or 3 [AUC-ROC of 0.79 (95% CI 0.74-0.84) and 0.74 (95% CI 0.69-0.79), respectively (p < 0.001)] with a best cutoff value of 1217 µg/L (sensitivity 74%, specificity 77%). Admission myoglobin added predictive value to two established models of AKI prediction and showed significant ability to reclassify subjects regarding AKI status, while admission CK did not. Decision curve analysis also revealed that myoglobin added net benefit to established predictive models. Admission myoglobin was better than CK at predicting development of significant rhabdomyolysis. CONCLUSIONS Admission myoglobin better predicts the development of AKI and severe rhabdomyolysis after major trauma. Admission myoglobin should be added in established predictive models of post-traumatic AKI to early identify high-risk patients.
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Affiliation(s)
- Virginie Tarazona
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU 12 "Anesthésie-Réanimation-Douleur", Université Paris Saclay, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Samy Figueiredo
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU 12 "Anesthésie-Réanimation-Douleur", Université Paris Saclay, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Sophie Hamada
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU 12 "Anesthésie-Réanimation-Douleur", Université Paris Saclay, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Jonas Pochard
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU 12 "Anesthésie-Réanimation-Douleur", Université Paris Saclay, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Ryan W Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, London, E1 1BB, UK.,William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Jacques Duranteau
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU 12 "Anesthésie-Réanimation-Douleur", Université Paris Saclay, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Bernard Vigué
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU 12 "Anesthésie-Réanimation-Douleur", Université Paris Saclay, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - Anatole Harrois
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), DMU 12 "Anesthésie-Réanimation-Douleur", Université Paris Saclay, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.
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Xu N, Jiang S, Persson PB, Persson EAG, Lai EY, Patzak A. Reactive oxygen species in renal vascular function. Acta Physiol (Oxf) 2020; 229:e13477. [PMID: 32311827 DOI: 10.1111/apha.13477] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/22/2020] [Accepted: 04/14/2020] [Indexed: 12/14/2022]
Abstract
Reactive oxygen species (ROS) are produced by the aerobic metabolism. The imbalance between production of ROS and antioxidant defence in any cell compartment is associated with cell damage and may play an important role in the pathogenesis of renal disease. NADPH oxidase (NOX) family is the major ROS source in the vasculature and modulates renal perfusion. Upregulation of Ang II and adenosine activates NOX via AT1R and A1R in renal microvessels, leading to superoxide production. Oxidative stress in the kidney prompts renal vascular remodelling and increases preglomerular resistance. These are key elements in hypertension, acute and chronic kidney injury, as well as diabetic nephropathy. Renal afferent arterioles (Af), the primary resistance vessel in the kidney, fine tune renal hemodynamics and impact on blood pressure. Vice versa, ROS increase hypertension and diabetes, resulting in upregulation of Af vasoconstriction, enhancement of myogenic responses and change of tubuloglomerular feedback (TGF), which further promotes hypertension and diabetic nephropathy. In the following, we highlight oxidative stress in the function and dysfunction of renal hemodynamics. The renal microcirculatory alterations brought about by ROS importantly contribute to the pathophysiology of kidney injury, hypertension and diabetes.
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Affiliation(s)
- Nan Xu
- Department of Physiology Zhejiang University School of Medicine Hangzhou China
| | - Shan Jiang
- Department of Physiology Zhejiang University School of Medicine Hangzhou China
| | - Pontus B. Persson
- Charité ‐ Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Institute of Vegetative Physiology Berlin Germany
| | | | - En Yin Lai
- Department of Physiology Zhejiang University School of Medicine Hangzhou China
- Charité ‐ Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Institute of Vegetative Physiology Berlin Germany
| | - Andreas Patzak
- Charité ‐ Universitätsmedizin Berlin Corporate Member of Freie Universität Berlin Humboldt‐Universität zu Berlin, and Berlin Institute of Health Institute of Vegetative Physiology Berlin Germany
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Acute Kidney Injury in Severe Trauma Patients; a Record-Based Retrospective Study. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2019; 3:e22. [PMID: 31410399 PMCID: PMC6683585 DOI: 10.22114/ajem.v0i0.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Introduction: Acute kidney injury (AKI) is a common and devastating clinical issue in the community associated with high rates of morbidity and mortality. Objective: We aimed at estimating the frequency and levels of severity of AKI in trauma patients requiring hospital admission using the RIFLE criteria and assess their outcome. Method: Our retrospective record based study enrolled data of 80 participants aged 18–59 years who presented to the emergency department of KIMS hospital following an acute traumatic event. Participants with pre-existing renal dysfunction, chronic heart failure and chronic liver disease were excluded. Tests of significance were Chi square and independent sample t test, a p<0.05 was considered statistically significant. Results: Participants with AKI had significantly lower age (p=0.02) and lower revised trauma score (RTS) (p=0.01). Significant association of AKI with hypotension (p=0.01) and Glasgow coma scale (GCS) (p=0.008) was observed. No association of AKI with gender was observed (p=0.6). None of the AKI patients required renal replacement therapy and all participants attained normal renal function at discharge. Significantly longer mean duration of hospital stay (14.4 days) was observed among AKI patients (p=0.02). Totally, 6.3 % mortality was observed among both participants with and without AKI. Conclusion: Forty percent of acute trauma patients had AKI (in risk and injury category); but none were in failure, loss or end stage renal disease. No association of AKI and mortality was observed. AKI was associated with age, RTS, hypotension and GCS.
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Breed D, Meyer LCR, Steyl JCA, Goddard A, Burroughs R, Kohn TA. Conserving wildlife in a changing world: Understanding capture myopathy-a malignant outcome of stress during capture and translocation. CONSERVATION PHYSIOLOGY 2019; 7:coz027. [PMID: 31304016 PMCID: PMC6612673 DOI: 10.1093/conphys/coz027] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 04/22/2019] [Accepted: 05/03/2019] [Indexed: 05/18/2023]
Abstract
The number of species that merit conservation interventions is increasing daily with ongoing habitat destruction, increased fragmentation and loss of population connectivity. Desertification and climate change reduce suitable conservation areas. Physiological stress is an inevitable part of the capture and translocation process of wild animals. Globally, capture myopathy-a malignant outcome of stress during capture operations-accounts for the highest number of deaths associated with wildlife translocation. These deaths may not only have considerable impacts on conservation efforts but also have direct and indirect financial implications. Such deaths usually are indicative of how well animal welfare was considered and addressed during a translocation exercise. Importantly, devastating consequences on the continued existence of threatened and endangered species succumbing to this known risk during capture and movement may result. Since first recorded in 1964 in Kenya, many cases of capture myopathy have been described, but the exact causes, pathophysiological mechanisms and treatment for this condition remain to be adequately studied and fully elucidated. Capture myopathy is a condition with marked morbidity and mortality that occur predominantly in wild animals around the globe. It arises from inflicted stress and physical exertion that would typically occur with prolonged or short intense pursuit, capture, restraint or transportation of wild animals. The condition carries a grave prognosis, and despite intensive extended and largely non-specific supportive treatment, the success rate is poor. Although not as common as in wildlife, domestic animals and humans are also affected by conditions with similar pathophysiology. This review aims to highlight the current state of knowledge related to the clinical and pathophysiological presentation, potential treatments, preventative measures and, importantly, the hypothetical causes and proposed pathomechanisms by comparing conditions found in domestic animals and humans. Future comparative strategies and research directions are proposed to help better understand the pathophysiology of capture myopathy.
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Affiliation(s)
- Dorothy Breed
- Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
- Biodiversity Management Branch, Environmental Management Department, City of Cape Town, Maitland, South Africa
| | - Leith C R Meyer
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Johan C A Steyl
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Amelia Goddard
- Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Richard Burroughs
- Department of Production Animal Studies, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
- Mammal Research Institute, University of Pretoria, Onderstepoort, South Africa
| | - Tertius A Kohn
- Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Corresponding author: Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Boundary Road, Cape Town 7725, South Africa. Tel.: +27 21 406 6235;
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Abstract
PURPOSE OF REVIEW To review epidemiology and pathophysiology of acute kidney injury (AKI) in trauma patients and propose strategies that aim at preventing AKI after trauma. RECENT FINDINGS AKI in trauma patients has been reported to be as frequent as 50% with an association to a prolonged length of stay and a raise in mortality. Among the specific risk factors encountered in trauma patients, hemorrhagic shock, rhabdomyolysis severity, age, and comorbidities are independently associated with AKI occurrence. Resuscitation with balanced solutes seems to have beneficial effects on renal outcome compared with NaCl 0.9%, particularly in the context of rhabdomyolysis. However, randomized clinical studies are needed to confirm this signal. Abdominal compartment syndrome (ACS) is rare but has to be diagnosed to initiate a dedicated therapy. SUMMARY The high incidence of AKI in trauma patients should lead to early identification of those at risk of AKI to establish a resuscitation strategy that aims at preventing AKI.
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