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Renal Tubular Acidosis Treatment Guidelines

Renal Tubular Acidosis

Renal Tubular Acidosis

Renal tubular acidosis (RTA) is acidosis and electrolyte disturbances due to impaired renal hydrogen ion excretion (type 1), impaired bicarbonate resorption (type 2), or abnormal aldosterone production or response (type 4). (Type 3 is extremely rare and is not discussed.) Patients may be asymptomatic, display symptoms and signs of electrolyte derangements, or progress to chronic kidney disease. Diagnosis is based on characteristic changes in urine pH and electrolytes in response to provocative testing. Treatment corrects pH and electrolyte imbalances using alkaline agents, electrolytes, and, rarely, drugs. RTA defines a class of disorders in which excretion of hydrogen ions or reabsorption of filtered bicarbonate is impaired, leading to a chronic metabolic acidosis with a normal anion gap. Hyperchloremia is usually present, and secondary derangements may involve other electrolytes, such as potassium (frequently) and calcium (rarelysee Table: Some Features of Different Types of Renal Tubular Acidosis* ). Chronic RTA is often associated with structural damage to renal tubules and may progress to chronic kidney disease . Some Features of Different Types of Renal Tubular Acidosis* Treatment of concomitant abnormalities related to potassium, calcium, and phosphate metabolism Treatment consists of correction of pH and electrolyte balance with alkali therapy. Failure to treat RTA in children slows growth. Alkaline agents such as sodium bicarbonate, potassium bicarbonate, or sodium citrate help achieve a relatively normal plasma bicarbonate concentration (22 to 24 mEq/L). Potassium citrate can be substituted when persistent hypokalemia is present or, because sodium increases calcium excretion, when calcium calculi are present. Vitamin D (eg, ergocalciferol 800 IU po once/day) Continue reading >>

Distal Renal Tubular Acidosis

Distal Renal Tubular Acidosis

Distal renal tubular acidosis (dRTA) or Type 1 renal tubular acidosis (RTA) is the classical form of RTA, being the first described. Distal RTA is characterized by a failure of acid secretion by the alpha intercalated cells of the cortical collecting duct of the distal nephron . This failure of acid secretion may be due to a number of causes, and it leads to an inability to acidify the urine to a pH of less than 5.3. Radiograph of a rickets sufferer, a complication of both distal and proximal RTA. Because renal excretion is the primary means of eliminating acid from the body, there is consequently a tendency towards acidemia . This leads to the clinical features of dRTA: [1] Urinary stone formation (related to alkaline urine, hypercalciuria , and low urinary citrate). [2] Nephrocalcinosis (deposition of calcium in the substance of the kidney) Bone demineralisation (causing rickets in children and osteomalacia in adults) The symptoms and sequelae of dRTA are variable and range from being completely asymptomatic , to loin pain and hematuria from kidney stones , to failure to thrive and severe rickets in childhood forms as well as possible renal failure and even death. dRTA commonly leads to sodium loss and volume contraction, which causes a compensatory increase in blood levels of aldosterone . [3] Aldosterone causes increased resorption of sodium and loss of potassium in the collecting duct of the kidney, so these increased aldosterone levels cause the hypokalemia which is a common symptom of dRTA. [3] The pH of patient's blood is highly variable, and acidemia is not necessarily characteristic of sufferers of dRTA at any given time. One may have dRTA caused by alpha intercalated cell failure without necessarily being acidemic; termed incomplete dRTA, which is characteri Continue reading >>

Orphanet: Distal Renal Tubular Acidosis

Orphanet: Distal Renal Tubular Acidosis

Prevalence of dRTA is unknown but is often underreported. The hereditary forms of dRTA are more prevalent in areas of high consanguinity (Arabic peninsula and North Africa) whereas acquired dRTA has been reported more frequently in Western countries. Disease onset can occur at any age, depending on cause. Hereditary dRTA subtypes include autosomal dominant (AD) and autosomal recessive (AR) dRTA (see these terms). A recessive subtype of dRTA associated with anemia has also been described in Southeast Asia. AR forms are frequently diagnosed in infants and young children. AD dRTA is mostly diagnosed in adolescents and young adults. Patients with dRTA can be asymptomatic or can present with polyuria, polydipsia, weakness and fatigue (symptoms associated with hypokalemia). Failure to thrive, rickets, stunting of growth (seen in children) and osteomalacia or osteopenia (seen in adults) are a result of urinary calcium wastage and a loss of calcium salts from the bones. Hypercalciuria, nephrolithiasis and nephrocalcinosis usually occur. Low plasma potassium levels in those with the classic form of dRTA can also cause cardiac arrhythmias, paralysis and even death. In the recessive forms of dRTA, progressive and irreversible deafness often occurs. dRTA can be acquired or inherited. AD dRTA is usually due to mutations in the SLC4A1 gene (17q21.31). Mutations in the ATP6V1B1 gene (2p13) or ATP6V0A4 gene (7q34) are responsible for AR dRTA with deafness. AR dRTA without deafness or late onset deafness has been mainly described in patients with mutations in the ATP6V0A4 gene but overlap does exist in that some patients with this mutation develop deafness and others do not. Acquired forms of dRTA are thought to be caused by autoimmune diseases such as Sjgren syndrome (see this term) o Continue reading >>

Common Drugs And Medications To Treat Renal Tubular Acidosis

Common Drugs And Medications To Treat Renal Tubular Acidosis

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11 Guidelines For Conservatively Treating Chronic Kidney Disease

11 Guidelines For Conservatively Treating Chronic Kidney Disease

The most commonly used intestinal phosphate-binding agents in dogs and cats contain aluminum as hydroxide, oxide, or carbonate salts.1 Aluminum-containing binding agents generally appear to be well-tolerated and safe in dogs and cats; as such, they probably represent first-choice drugs for phosphate binding. Alternative drugs include calcium carbonate, calcium acetate, sevelamer hydrochloride (Renagel Geltex), or lanthanum carbonate (FosrenolShire). Experience with these drugs in dogs and cats is limited, but hypercalcemia may be a problem with the calcium-based products, particularly when they are administered with calcitriol. An intestinal phosphate binder composed of a mixture of calcium carbonate and chitosan is marketed for use in dogs and cats (EpakitinVtoquinol). Moderate evidence (grade 2) supports a phosphorus-restricted diet in dogs with chronic kidney disease6; however, the evidence in cats with chronic kidney disease is less sound (grade 4).4 While strong evidence supports feeding a renal diet to both dogs and cats with chronic kidney disease, the specific effect of phosphorus intake on clinical outcome has only been documented in dogs with induced chronic kidney disease in which dietary phosphorus restriction was shown to slow the progression of chronic kidney disease and improve survival.6 Once therapeutic targets have been attained, re-evaluate dogs and cats in stages 2 through 4 every three to four months to ensure continued compliance and therapeutic success at maintaining the target. #4 Maintain serum potassium concentrations within the target range. Intervention to manage serum potassium concentrations is indicated in dogs and cats when the concentrations fall outside the target range of 3.5 to 5.5 mEq/L, regardless of the chronic kidney disease stag Continue reading >>

Renal Tubular Acidosis

Renal Tubular Acidosis

Renal tubular acidosis (RTA) refers to the non-anion gap metabolic acidosis which develops due to derangement of usual metabolic processes in the kidneys. The kidneys have a critical role in maintaining stable physiologic pH and they do so through several mechanisms throughout the nephron. Proximally, filtered bicarbonate is resorbed and distally acid is excreted then buffered in the urine. If the kidneys lose the ability to carry out these functions, renal tubular acidosis results. The three major forms of renal tubular acidosis are differentiated by the specific type and location of the mechanistic defect. An understanding of the basic physiology of the handling of acid by the kidney allows one to use clinical and laboratory clues to diagnose the type of RTA. The three key renal mechanisms to handle acid are listed below with the form of RTA associated with defects at that site. Reclaiming filtered bicarbonate in the proximal tubule - proximal (type 2) renal tubular acidosis The reclamation of bicarbonate is accompanied by excretion of a proton (H+) and occurs primarily in the proximal tubule (90% of filtered bicarbonate). A decrease in proximal tubular bicarbonate resorptive capacity results in proximal (type 2) RTA. During the development of proximal RTA, bicarbonate is excreted into the urine because the filtered concentration exceeds the resorptive threshold of the proximal tubule, raising the urine pH. However, due to urinary loss, the subsequent serum and filtered bicarbonate concentrations decrease below the resorptive threshold such that filtered bicarbonate is then resorbed normally. Therefore the bicarbonaturia is self-limited and the serum bicarbonate concentration usually stabilizes between 14 and 20 meq/L. The urine pH is only transiently elevated during Continue reading >>

Successful Management Of Refractory Type 1 Renal Tubular Acidosis With Amiloride

Successful Management Of Refractory Type 1 Renal Tubular Acidosis With Amiloride

Successful Management of Refractory Type 1 Renal Tubular Acidosis with Amiloride 1Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA 2Division of Nephrology, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA 3Department of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, MD, USA 4Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 5Nephrology Center of Maryland, Baltimore, MD, USA Correspondence should be addressed to Patrick Oguejiofor ; [email protected] Received 14 July 2016; Revised 2 December 2016; Accepted 14 December 2016; Published 3 January 2017 Copyright 2017 Patrick Oguejiofor et al. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A 28-year-old female with history of hypothyroidism, Sjgrens Syndrome, and Systemic Lupus Erythematosus (SLE) presented with complaints of severe generalized weakness, muscle pain, nausea, vomiting, and anorexia. Physical examination was unremarkable. Laboratory test showed hypokalemia at 1.6 mmol/l, nonanion metabolic acidosis with HCO3 of 11 mmol/l, random urine pH of 7.0, and urine anion gap of 8 mmol/l. CT scan of the abdomen revealed bilateral nephrocalcinosis. A diagnosis of type 1 RTA likely secondary to Sjgrens Syndrome was made. She was started on citric acid potassium citrate with escalating dosages to a maximum dose of 60 mEq daily and potassium chloride over 5 years without significant improvement in serum K+ and HCO3 levels. She had multiple emergency room visits for persistent muscle pain, generalized weakness, Continue reading >>

Renal Tubular Acidosis (rta)

Renal Tubular Acidosis (rta)

Renal Tubular Acidosis (RTA) is a disease of the kidneys Namely the renal tubules. There are three main types of renal tubular acidosis Type one, type two, and type four. Type three renal tubular acidosis is a term no longer used for its defining feature resolved with age and was not part of the pathological process. The type of RTA is assigned depending on which part of the acid handling mechanism is affected. Statistics on Renal Tubular Acidosis (RTA) There are no widely accepted statistics on the rate of RTA. The disease, however, does occur at any age and afflicts men more so than women. Risk Factors for Renal Tubular Acidosis (RTA) Type 1 This condition may be inherited or acquired. In the majority of cases, this form of RTA results from the presence of another disease such as Sjogrens syndrome , hypergammaglobulinaemia, chronic active hepatitis and systemic Lupus Erythematosus. Type 2 This condition may also be inherited or acquired. The pattern of inheritance in this condition is more unpredicyable than that of type 1 RTA. This condition may also be present in associated with other disease states such as Fanconi Syndrome and can be induced by certain drugs such as acetazolamide. Type 4 This condition cannot be inherited and is exclusively acquired. It occurs in patients with poor kidney function and may arise or be made worse with the use of drugs such as trimethoprim, anti-inflammatory drugs, ACE inhibitors and heparin. Progression of Renal Tubular Acidosis (RTA) This condition causes prolonged blood acidity increasing the breakdown of calcium within the bony skeleton of the body. This increases the concentration of calcium within the bloodstream. More calcium is therefore allowed to enter the kidneys. In the presence of blood acidity, the kidneys are unable to Continue reading >>

Renal Tubular Acidosis | American Academy Of Pediatrics Textbook Of Pediatric Care, 2nd Edition | Pediatric Care Online | Aap Point-of-care-solutions

Renal Tubular Acidosis | American Academy Of Pediatrics Textbook Of Pediatric Care, 2nd Edition | Pediatric Care Online | Aap Point-of-care-solutions

This is the touchback warning message modal. The following terms and conditions are an agreement (the Agreement) governing your access and use of the [Pediatric Care Online (PCO)] website(the Website) and its content (collectively, the Materials). Please read these terms carefully. If you agree to all of the terms ofthis Agreement please click the I Agree button below to indicate your acceptance and you will automatically be taken to the Website. If you do notwish to be bound by these terms, you may not access or use the Materials - in such event you should click the I Do Not Agree button below and followthe instructions to obtain a refund of any subscription fees paid by you. 1. Materials. The American Academy of Pediatrics (AAP) hosts the Website and related Materials on its servers and makesthem available via the Internet to subscribers for non-commercial research and education purposes and for use in providing healthcare services. Inconsideration of payment of the applicable subscription fee, the AAP is willing to provide access to the Materials to you and, if applicable, your Users(as defined below), subject to all of the following terms. You acknowledge that certain portions or content of the Website or Materials may containinformation, materials or content provided by a third party provider or licensor (a Provider) and that the liability and obligations of suchProviders is limited as provided herein. (a) Subject to the terms of this Agreement, the AAP grants to you a non-exclusive, non-assignable and non-transferable right to access and use theMaterials for the purpose of providing healthcare services to your patients (the License). (b) User means you and your authorized users for whom a subscription has been activated. For individual enrollment use of the Mater Continue reading >>

Genetic Causes And Mechanisms Of Distal Renal Tubular Acidosis

Genetic Causes And Mechanisms Of Distal Renal Tubular Acidosis

Genetic causes and mechanisms of distal renal tubular acidosis Northwestern University Feinberg School of Medicine Correspondence and offprint requests to: Daniel Batlle; E-mail: [email protected] Search for other works by this author on: Northwestern University Feinberg School of Medicine Nephrology Dialysis Transplantation, Volume 27, Issue 10, 1 October 2012, Pages 36913704, Daniel Batlle, Syed K. Haque; Genetic causes and mechanisms of distal renal tubular acidosis, Nephrology Dialysis Transplantation, Volume 27, Issue 10, 1 October 2012, Pages 36913704, The primary or hereditary forms of distal renal tubular acidosis (dRTA) have received increased attention because of advances in the understanding of the molecular mechanism, whereby mutations in the main proteins involved in acidbase transport result in impaired acid excretion. Dysfunction of intercalated cells in the collecting tubules accounts for all the known genetic causes of dRTA. These cells secrete protons into the tubular lumen through H+-ATPases functionally coupled to the basolateral anion exchanger 1 (AE1). The substrate for both transporters is provided by the catalytic activity of the cytosolic carbonic anhydrase II (CA II), an enzyme which is also present in the proximal tubular cells and osteoclasts. Mutations in ATP6V1B1, encoding the B-subtype unit of the apical H(+) ATPase, and ATP6V0A4, encoding the a-subtype unit, lead to the loss of function of the apical H(+) ATPase and are usually responsible for patients with autosomal recessive dRTA often associated with early or late sensorineural deafness. Mutations in the gene encoding the cytosolic CA II are associated with the autosomal recessive syndrome of osteopetrosis, mixed distal and proximal RTA and cerebral calcification. Mutations in Continue reading >>

Renal Tubular Acidosis (rta)

Renal Tubular Acidosis (rta)

By L. Aimee Hechanova, MD, Assistant Professor of Medicine, Texas Tech University; Attending Nephrologist, University Medical Center (See also Introduction to Disorders of Kidney Tubules .) In renal tubular acidosis, the kidney tubules malfunction, resulting in excess levels of acid in the blood. The tubules of the kidneys that remove acid from the blood are damaged when a person takes certain drugs or has another disorder that affects the kidneys. Often muscle weakness and diminished reflexes occur when the disorder has been present for a long time. Blood tests show high acid levels and a disturbance of the body's acid-base balance. Some people drink a solution of baking soda every day to neutralize the acid. To function normally, body acids and alkali (such as bicarbonate) must be balanced. Normally, the breakdown of food produces acids that circulate in the blood. The kidneys remove acids from the blood and excrete them in the urine. This function is predominantly carried out by the kidney tubules . In renal tubular acidosis, the kidney tubules malfunction in one of two ways that tend to increase acids in the blood ( metabolic acidosis ): Too little of the acids the body produces are excreted, so acid levels in blood increase. Too little of the bicarbonate that filters through the kidney tubules is reabsorbed, so too much bicarbonate is lost in the urine. In renal tubular acidosis, the balance of electrolytes is also affected. Renal tubular acidosis may lead to the following problems: Low or high potassium levels in the blood Calcium deposits in the kidneys, which may lead to kidney stones Painful softening and bending of the bones (osteomalacia or rickets ) Renal tubular acidosis may be a permanent, inherited disorder in children. However, it may be an intermittent Continue reading >>

Renal Tubular Acidosis (rta): Types, Causes, Symptoms, Diagnosis & Treatment

Renal Tubular Acidosis (rta): Types, Causes, Symptoms, Diagnosis & Treatment

Renal Tubular Acidosis or RTA is a kidney disease in which the kidneys are unable to maintain the acid-base balance in the body. The condition causes increased acidic contents in the blood and decreases excretion of acid molecules in urine. In this article, we will read about the different causes, symptoms, and treatments for Renal Tubular Acidosis. Renal Tubular Acidosis (RTA) causes accumulation of acidic content in the body Increased accumulation of acid in the blood is caused by kidney failure resulting in decreased excretion of acid in urine. Acid content in the blood increases because of following reason- Kidney is unable to retain alkaline molecules or bicarbonates. Kidney retains and is unable to discharge hydrogen molecules or acid content in the urine. Renal tubular acidosis causes metabolic acidosis. Renal tubular acidosis reduces blood pH resulting in academia. This condition is also called Distal Renal Tubular Acidosis. This is one of the most common forms of Renal Tubular Acidosis. The disease is caused by reduced hydrogen (acid) molecules excretion in distal tubule and increased excretion of HCO3 (alkaline) molecule. The H+ molecule is reabsorbed as acid molecule causing decreased blood pH or acidic pH resulting in metabolic acidosis. Type 1 Renal Tubular Acidosis is associated with renal stone.1 Plasma HCO3 level is less the 15 mEq/L (normal level over 23 mEq/L). Plasma K level is low resulting in hypokalemia.1 This condition is associated with high levels of calcium in the blood Renal tubular acidosis is often observed in patients suffering with sickle cell disease, lupus and Sjogren syndrome. This disease is also known as Proximal Renal Tubular Acidosis. The defect is in close proximity to the origin of the tubule. Disease is caused by defects in proxi Continue reading >>

Renal Tubular Disease

Renal Tubular Disease

Zhuo JL, Li XC ; Proximal nephron. Compr Physiol. 2013 Jul3(3):1079-123. doi: 10.1002/cphy.c110061. Fiseha T, Gebreweld A ; Urinary Markers of Tubular Injury in HIV-Infected Patients. Biochem Res Int. 20162016:1501785. doi: 10.1155/2016/1501785. Epub 2016 Jul 17. Bagga A et al ; Approach to Renal Tubular Disorders Indian Journal of Pediatrics Volume 72-September, 2005. Distal renal tubular acidosis ; Orphanet, 2014 Rehman HU ; A woman with generalised weakness, hypokalaemia, and metabolic acidosis. BMJ. 2012 Apr 12344:e2545. doi: 10.1136/bmj.e2545. Both T, Zietse R, Hoorn EJ, et al ; Everything you need to know about distal renal tubular acidosis in autoimmune disease. Rheumatol Int. 2014 Aug34(8):1037-45. doi: 10.1007/s00296-014-2993-3. Epub 2014 Mar 29. Renal tubular acidosis ; BMJ Best Practice, 2016. Walsh SB, Unwin RJ ; Renal tubular disorders. Clin Med October 1, 2012 vol. 12 no. 5 476-479. Goswami RP, Mondal S, Karmakar PS, et al ; Type 3 renal tubular acidosis. Indian J Nephrol. 2012 Nov22(6):466-8. doi: 10.4103/0971-4065.106058. Haas CS, Pohlenz I, Lindner U, et al ; Renal tubular acidosis type IV in hyperkalaemic patients--a fairy tale or reality? Clin Endocrinol (Oxf). 2013 May78(5):706-11. doi: 10.1111/j.1365-2265.2012.04446.x. Karunarathne S, Udayakumara Y, Govindapala D, et al ; Type IV renal tubular acidosis following resolution of acute kidney injury and disseminated intravascular coagulation due to hump-nosed viper bite. Indian J Nephrol. 2013 Jul23(4):294-6. doi: 10.4103/0971-4065.114476. Prasad N, Bhadauria D ; Renal phosphate handling: Physiology. Indian J Endocrinol Metab. 2013 Jul17(4):620-7. doi: 10.4103/2230-8210.113752. Moutzouri E, Liberopoulos EN, Elisaf M ; Life-threatening hypophosphataemia in a cirrhotic patient with jaundice. Arch Med Sci Continue reading >>

Renal Tubular Acidosis

Renal Tubular Acidosis

Each time our internal organs do something, such as digesting food or healing damaged tissue, chemical reactions take place in the body's cells. These reactions cause acid to go into the bloodstream. Normally, the kidneys remove excess acid from blood, but certain diseases, genetic defects, or drugs can damage a kidney's ability to do this important job. This can allow too much acid to build up in the blood and cause problems. When this happens, it's called renal tubular acidosis (RTA). Without treatment, RTA can affect a child's growth and cause kidney stones , fatigue, muscle weakness, and other symptoms. Over time, untreated acidosis can lead to long-term problems like bone disease, kidney disease , and kidney failure. Fortunately, such complications are rare, since most cases of RTA can be effectively treated with medicines or by treating the condition that's causing the acid to build up. The kidneys are a pair of bean-shaped organs located toward the back of the abdominal cavity, just above the waist. The kidneys remove waste products and extra water from the food a person eats, returning chemicals the body needs (such as sodium, phosphorus, and potassium) back into the bloodstream. The extra water combines with other waste to become urine (pee). The main functional units of the kidneys, where the blood filtering happens, are tiny structures called nephrons. Each kidney has about a million nephrons, and each nephron has a renal tubule, a tube where the acid and waste products filtered from the blood are secreted into urine. Having a disease or defect can interfere with how the renal tubules function, which can lead to RTA. There are a few different kinds of RTA. The first two types are named for the part of the renal tubule in which the damage or defect is found. Continue reading >>

Metabolic Acidosis Treatment & Management: Approach Considerations, Type 1 Renal Tubular Acidosis, Type 2 Renal Tubular Acidosis

Metabolic Acidosis Treatment & Management: Approach Considerations, Type 1 Renal Tubular Acidosis, Type 2 Renal Tubular Acidosis

Metabolic AcidosisTreatment & Management Author: Christie P Thomas, MBBS, FRCP, FASN, FAHA; Chief Editor: Vecihi Batuman, MD, FASN more... Treatment of acute metabolic acidosis by alkali therapy is usually indicated to raise and maintain the plasma pH to greater than 7.20. In the following two circumstances this is particularly important. When the serum pH is below 7.20, a continued fall in the serum HCO3- level may result in a significant drop in pH. This is especially true when the PCO2 is close to the lower limit of compensation, which in an otherwise healthy young individual is approximately 15 mm Hg. With increasing age and other complicating illnesses, the limit of compensation is likely to be less. A further small drop in HCO3- at this point thus is not matched by a corresponding fall in PaCO2, and rapid decompensation can occur. For example, in a patient with metabolic acidosis with a serum HCO3- level of 9 mEq/L and a maximally compensated PCO2 of 20 mm Hg, a drop in the serum HCO3- level to 7 mEq/L results in a change in pH from 7.28 to 7.16. A second situation in which HCO3- correction should be considered is in well-compensated metabolic acidosis with impending respiratory failure. As metabolic acidosis continues in some patients, the increased ventilatory drive to lower the PaCO2 may not be sustainable because of respiratory muscle fatigue. In this situation, a PaCO2 that starts to rise may change the plasma pH dramatically even without a significant further fall in HCO3-. For example, in a patient with metabolic acidosis with a serum HCO3- level of 15 and a compensated PaCO2 of 27 mm Hg, a rise in PaCO2 to 37 mm Hg results in a change in pH from 7.33 to 7.20. A further rise of the PaCO2 to 43 mm Hg drops the pH to 7.14. All of this would have occurred whi Continue reading >>

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