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Chronic Kidney Disease

What is Chronic kidney disease?  

Chronic kidney disease(CKD) is a condition where the filtering units of healthy kidneys undergo slow damage. Due to this, the kidneys are unable to function properly leading to an increase in the levels of metabolic waste products and fluids in the body. Chronic Kidney disease (CKD)is a progressive condition, that could get worse with time and terminates in End-stage renal disease This is most commonly seen in the elderly population but people and children of other ages can also get affected by it. 

Chronic kidney disease(CKD) mostly is secondary to chronic conditions such as diabetes mellitus and hypertension. As the incidences of these diseases are increasing all over the world, consequently the cases of Chronic kidney disease (CKD) are also increasing. According to a survey done by WHO in 2020, Chronic kidney disease(CKD) has been ranked as the 10th leading cause of death worldwide (5) and it is predicted that it will rise further to become the fifth leading cause of death by 2040(6). In 2017, CKD resulted in 2.6 million deaths worldwide; In India, 15-16 % of the population is affected by chronic kidney disease(CKD) 

 

Before getting into the details of Chronic kidney disease(CKD) let us first see what are the functions of a healthy kidney-

  1. It helps to filter out the metabolic waste products from our body eg - Creatinine, urea, uric acid, etc   
  2. It helps to filter out the breakdown products of certain medicines eg-certain antibiotics, psychiatric medicines, beta-blockers, diuretics, etc.
  3. It helps to maintain the electrolyte balance in the body.
  4. Maintain the acid-base balance in the body.
  5. Maintain the water balance in the body 
  6. Secrete hormone Erythropoietin helps in stimulating the production and maintenance of the red blood cells  
  7. Secrete hormone Renin helps to regulate the blood pressure along with Aldosterone and angiotensin hormones
  8. Secrete hormone Calcitriol helps for improved calcium absorption from the intestines and improved bone health.

 

A person is said to be suffering from chronic kidney disease(CKD) when his creatinine levels rise above 1.2 mg/dL- and GFR falls below 90mL/min/1.73m2

 

What is creatinine? 

It is a waste product of protein metabolism. It is a breakdown product of creatine phosphate - which is normally present in the muscles and is utilized for energy production by the muscles. Creatinine is present in the blood that passes through the kidneys for filtration. In the kidneys, the glomerulus filters out creatinine and other metabolic waste and water to form urine. Creatinine does not get reabsorbed again into the blood. Hence creatinine levels serve as a marker for kidney function.

 

However, estimation of kidney function is not to be done solely based on creatinine levels itself as other conditions can cause temporarily elevated creatinine levels without any underlying kidney pathology. Increased intake of creatine supplements - used for bodybuilding could increase the amount of creatinine being excreted in the urine. Also, the extent of creatinine produced is directly proportional to the muscle mass. Hence more the muscle mass, the higher the creatinine generated. Also, the creatinine levels could be high if a person is dehydrated at the time of giving blood samples to the lab.

 

What is GFR?

GFR is glomerular filtration rate. Our kidneys are made up of cells called nephrons. These nephrons are also called filtering units of the kidneys. Each nephron comprises renal tubules and glomerulus. GFR gives us an estimate of how much blood passes through a glomerulus each minute. The range of GFR varies with age and the body mass index. Thus children have different GFR values than adults. A normal GFR value is between 90-120 mL/min/1.73m2

Due to some reasons listed below, the nephrons start to lose their filtering ability. But the other healthy nephrons overwork to compensate for this loss of function. As a result, the kidney can perform its work properly. As the condition progresses, more and more nephrons lose their ability to function, as well as the present nephrons, get overworked, thus further gradually reducing the kidneys' filtering capacity. The waste such as creatinine, urea, electrolytes, fluids, and other metabolic waste that were being excreted now start accumulating in the blood, giving rise to symptoms of chronic kidney disease(CKD). It is because of the compensatory mechanism of the nephrons, that by the time a person is diagnosed with Chronic kidney disease(CKD), half of the kidney cells have already stopped functioning.

 

Risk factors for chronic kidney disease(CKD)  

  1. Uncontrolled Diabetes mellitus 
  2. Uncontrolled blood pressure 
  3. Heart disease 
  4. Having underlying kidney conditions like chronic glomerulonephritis, pyelonephritis, nephrotic syndrome, etc, polycystic kidneys, focal segmental glomerulosclerosis, membranous nephropathy, crescentic glomerulonephritis
  5. Increasing age
  6. Obesity 
  7. Smoking 
  8. Taking certain medicines and herbal supplements for a prolonged time 
  9. Certain autoimmune conditions such as Lupus, IgA Nephropathy, Scleroderma 
  10. Family history of kidney diseases 

 

In the causes section, we shall learn how the individual cause leads to Chronic kidney disease(CKD)  

 

Causes for Chronic kidney disease(CKD) 

1) Type 1 and type 2 diabetes mellitus -It is said that Diabetes is one of the leading causes of chronic kidney disease(CKD) 

People with type 1 and type 2 diabetes often end up with a kidney condition called Diabetic nephropathy, which further progresses to Chronic kidney disease(CKD). A high level of sugar in blood damages the tiny blood vessels present in the kidneys. This damage occurs slowly, over many years leading to Chronic kidney disease(CKD). One is more likely to develop chronic kidney disease(CKD) early if the blood sugar is not under control. 

 

2) High blood pressure- High blood pressure is the second leading cause of CKD worldwide. The relation of high blood pressure and chronic kidney disease(CKD) is like a vicious cycle, each one influences the other. Due to uncontrolled high blood pressure, there is narrowing, hardening of the blood vessels in the kidneys. This affects the glomerular blood flow and the filtration rate leading to the accumulation of toxic metabolic waste products in the body. And a progressive Chronic kidney disease(CKD) would lead to high blood pressure which is difficult to come under control.

 

3) Glomerular nephritis -This is a condition where there is inflammation of the glomeruli leading to loss of its function and damage, thus reducing the filtering capacity of the kidneys. This is the third leading cause of Chronic kidney disease(CKD)accounting for 10% of the patients on dialysis.

 

4) Recurrent kidney infection, also called pyelonephritis can cause damage to the kidneys leading to chronic kidney disease(CKD)

 

5) Vesicoureteral reflux- This is most commonly seen in younger children. This is a condition where the urine, instead of flowing from the bladder to the urethra, flows to the ureters and into the kidneys. This backflow is often with a force and also introduces bacteria into the kidneys. Recurrent backflow, if left untreated for long could damage the kidneys leading to scarring of kidneys, preventing its further growth and chances of developing high blood pressure in the future.

 

6) Polycystic kidneys -in this condition, there is the formation of cysts in the kidneys which damage the original tissues of the kidneys leading to chronic kidney disease(CKD). Poly-cystic kidneys cause Chronic kidney disease(CKD) which may further lead to Renal failure.

 

7) Prolonged obstruction of the urinary tract due to conditions such as hydro ureter caused by impaction of kidney stones in ureters and certain tumors and cancers which affects the flow of urine from kidneys to the bladder can cause damage to the kidney tissues leading to chronic kidney disease(CKD)

 

8) Intake of nephrotoxic( substances that are harmful to kidneys) drugs like chemotherapy agents, aminoglycoside, amphotericin B, penicillin radio-contrast dye, certain NSAIDs, herbal and Ayurveda medicines with heavy metals like arsenic and mercury. ( click here to know about list of nephrotoxic drugs )

 

9) Smoking- It causes hardening and narrowing of the arteries and hence reduced blood flow to the kidneys causing Chronic kidney disease(CKD) over some time. In the Cardiovascular Health Study cohort, smoking was independently associated with an increase in serum creatinine for every 5 cigarettes per day, resulting in a 0.3 mg/dL rise in serum creatinine).

 

10) Certain autoimmune conditions such as Systemic lupus, IgA nephropathy, Good pastures syndrome, kidney amyloidosis, Scleroderma could also damage the kidney tissues and blood vessels leading to Chronic kidney disease(CKD)

 

11) Aging - The amount of functioning kidney tissues reduces as the personages. Also, the arteries of the kidneys get hardened.

 

12) Obesity- when a person is overweight, there is an extra load on the kidneys to filter the extra metabolic wastes. This, over a while, can lead to CKD. Besides this, it is also known that being obese increases the risk for Diabetes Mellitus and High blood pressure which in long run cause Chronic kidney disease(CKD).

 

Stages of Chronic Kidney disease 

Chronic Kidney disease is divided into 5 stages based on the level of the functioning of the kidneys. It is calculated based on the patient's estimated GFR

The formula to calculate eGFR in adults is as below:

eGFR (mL/min)= [(140 - age) x Wt / (0.814 x S.Cr in Umol/L)] x (0.85 if female)

 

Stage 1- With normal or high GFR (GFR > 90 mL/min)- mild kidney damage with normal kidney function

Stage 2 -Mild CKD (GFR = 60-89 mL/min)- mild loss of kidney function

Stage 3A -Moderate CKD (GFR = 45-59 mL/min) mild to moderate loss of kidney function

Stage 3B- Moderate CKD (GFR = 30-44 mL/min)moderate to severe loss of kidney function

Stage 4 -Severe CKD (GFR = 15-29 mL/min)- severe loss of kidney function 

Stage 5 -End Stage CKD (GFR <15 mL/min)- kidney failure or end stage renal disease  

 

Symptoms of chronic kidney disease:

As other nephrons compensate for the loss of kidney function, there are almost no symptoms initially. The symptoms develop slowly over a period of time as the condition progresses. But patients with preexisting kidney conditions such as polycystic kidneys or nephrotic syndrome, glomerulonephritis may develop the signs of Chronic kidney disease(CKD) at a much earlier stage than the others. The symptoms develop as a result of an accumulation of metabolic waste, electrolyte imbalance, and excess fluid accumulation in the body.

 

Below are the stage-wise symptoms of Chronic kidney disease(CKD): 

Stage 1- High blood pressure, swelling in legs, urinary tract infections, albumin urea  

Stage 2-High blood pressure, swelling in legs, urinary tract infections, albumin urea  

Stage 3A-Reduced urine output, swelling in hands and feet, weakness or fatigue, dry and itchy skin, back pain, muscle cramping

Stage 3B-Reduced urine output, swelling in hands and feet, weakness or fatigue, dry and itchy skin, back pain, muscle cramping

Stage 4-Anemia, due to decreased renal synthesis of erythropoietin, fatigue, decreased appetite, abnormal levels of phosphorus, calcium, vitamin D leading to bone affections 

Stage 5-Uremia, fatigue, shortness of breath, nausea, vomiting, abnormal parathyroid levels, swelling in hands/legs/eyes/lower back, lower back pain

 

Besides these, the patients may also experience symptoms of 

Peripheral neuropathy is caused due to alteration of the nerve function due to electrolyte imbalance. This is called uremic neuropathy. Electrolyte imbalance can also affect one's mood, sleep causing sleep disturbances, loss of libido, and erectile dysfunction.

There is an increased tendency to bleeding caused due to anemia, poor medicine clearance and built up of medicines in the body, use of anticoagulants in patients undergoing dialysis. This bleeding is mostly from the upper gastrointestinal tract.

 

High blood pressure is uncontrollable. 

Fluid build up in the lungs could cause difficulty in breathing 

Fluid built up in the heart could cause pericarditis and cardiac tamponade 

Uremic encephalopathy is seen in patients with grade 5 Chronic kidney disease(CKD) who are not on dialysis. The patient may have symptoms of mental dullness, confusion, mood changes, vomiting, and coma.

 

Complications of CKD 

  1. High blood pressure, arteriosclerosis leading to cardiac issues 
  2. Electrolyte imbalance leading to seizures, 
  3. Hormonal imbalance may lead to loss of libido, menstrual irregularities, and infertility 
  4. Nausea and vomiting, weight loss, failure to gain weight, fatigue 
  5. Anaemia, low platelet count lead to bleeding risk
  6. Uremic neuropathy, seizures 
  7. Due to the involvement of the parathyroid gland there could be an increased rate of osteoporosis and bone fractures 
  8. Itchy skin due to increased urea levels 
  9. Excess water retention in lungs and heart May cause pleural effusion and cardiac tamponade 
  10. Untreated Chronic kidney disease(CKD) will lead to death 

 

Investigation for CKD -

Blood tests -

1- Complete blood count -is normal in the earlier stages, but as Chronic kidney disease(CKD) progresses, especially in stages 4 and 5, the RBC and Hemoglobin count falls significantly. A patient may also show macrocytic anemia due to Vitamin B12 and folic acid deficiency. In advanced cases on dialysis, the red blood cell morphology may show changes and due to hemodilution, there could be a reduction in hematocrit.

 

A 2-Renal profile which includes 

a- Serum creatinine- levels of serum creatinine increase as the Chronic kidney disease(CKD) progresses. Click here to know more about the details (link with creatinine at the start of the article)

b- Glomerular filtration rate. Click here to know more about the details (link with GFR at the start of the article)

c- Blood urea nitrogen- commonly known as BUN comes from the breakdown of protein from your diet. A normal BUN level is between 7-20. As the kidney function decreases the BUN level in blood rises.

d- Blood urea -Urea again is a breakdown product of protein metabolism and is filtered by the 

kidneys. Its levels in the blood rise progressively in Chronic kidney disease(CKD) as the kidneys are unable to filter it from the blood.

 

3- Serum electrolytes-includes test for checking levels of Serum sodium, Potassium, Chlorides, Phosphorus, and Bicarbonates 

A-Serum Sodium level-may increase or become low depending on the grade of Chronic kidney disease(CKD) and use of diuretics.

B- Serum Potassium level may increase progressively as Chronic kidney disease(CKD) advances

C- Serum Chloride - level may reduce along with serum sodium levels as the condition progresses.

D-Serum Phosphorus -level may increase as the kidneys lose their ability to filter out excess phosphorus from the blood

E- Serum Bicarbonate levels - the levels could be high or low depending on the grade of Chronic kidney disease(CKD), the use of diuretics, and frequency of dialysis.

 

2- Urine analysis- this simple test could give some indications about the underlying Chronic kidney disease(CKD), especially if Chronic kidney disease(CKD) is diagnosed accidentally in a routine check-up for some other conditions. Urine protein is the important element that indicates Kidney damage. A normal sample of urine does not contain any protein. As the kidneys start to get damaged, protein leak in urine could be noticed as microalbuminuria and progress to albuminuria. Below urine tests help diagnose and monitor patients with chronic kidney disease(CKD).

 

a- Urine protein test- done by dipstick or by getting the sample checked in a laboratory

 

b- Microalbuminurea- Checking for microalbumin in urine gives an idea about the early onset of chronic kidney disease(CKD)especially stage 1 and 2 when there are no other obvious symptoms. The first-morning urine sample is collected.

 

c -Urine spot protein also measures the number of proteins in the urine when the sample is given at any time of the day.

 

d-Urine culture and sensitivity in cases of chronic recurrent urinary tract and kidney infections 

 

e-24 hours urine output measuring-

 

Miscellaneous tests:

1- Serum proteins- which may indicate low serum albumin levels 

2-Serum parathyroid levels- are often high 

3-25 Hydroxy Vit D -shows low levels of 25 Hydroxy Vit D 

4-Alkaline phosphatase -Levels of Serum Alkaline phosphatase will be high 

5-Serum Cystatin level- this is often elevated in patients with CKD 

6 -Lipid profile - The levels may /may not be elevated. 

 

In certain cases of chronic kidney disease(CKD), the following tests are ordered to identify the underlying cause of the condition

1-Antinuclear antibodies for Systemic Lupus 

2-Monoclonal proteins

3-Serum complement levels 

4-Cytoplasmic and perinuclear pattern antineutrophil cytoplasmic antibody (C-ANCA and P-ANCA) levels: Positive 

5-Anti–glomerular basement membrane (anti-GBM) antibodies: 

6-Tests for Hepatitis B and C, HIV ( human immune deficiency virus), and Venereal Disease  

 

Imaging studies 

-

Xray-is not diagnostic of Chronic kidney disease(CKD) but used to identify any renal stones  

 

Ultrasound- used to identify any underlying renal pathologies such as polycystic kidneys, renal artery stenosis, and hydronephrosis. Initially, the kidneys may not show any changes but as the pathology advances, the ultrasound may reveal the reduced thickness of the renal cortex, reduced length, increased renal cortical echogenicity. 

 

Renal Doppler-for imaging of the intrarenal blood vessels and blood flow. In the initial stages, the findings would be normal. In advanced stages, there may be reduced renal vascularity and increased blood flow resistance.

 

Ct Scan- is used for identifying kidney lesions such as cysts, tumors, abscess, obstruction, etc. This is not routinely ordered as people with chronic kidney disease(CKD) may not tolerate the dye used in the contrast.

 

MRI can be indicated in the pts who cannot undergo CT scan contrast dye. However not commonly used to diagnose chronic kidney disease(CKD). It is used to accurately identify if there is an etiological factor for Chronic kidney disease(CKD)

 

Dimercaptosuccinic acid scintigraphy (DMSA)-This scan is done with the help of a radioisotope that lives for a very short time inside the body. Usually done in the children, with recurrent UTI to know how many areas of kidneys are functioning and if there is any scarring in the kidneys.

 

Kidney biopsy -This procedure involves taking out a small piece of kidney tissue with a needle and examining it under a microscope to see the type of microscopic changes that have occurred to the kidney tissues. Findings of kidney biopsy help to differentiate one type of kidney disorder from another.

 

Treatment -

The treatment of chronic kidney disease(CKD) mainly focuses on identifying the cause of chronic kidney disease(CKD), correcting it, thus slowing down the further damage to kidneys and in turn progression of the condition -

 

This usually involves- 

A- Medications -Medications are usually prescribed to lower the blood pressure, treat the uncontrolled diabetes mellitus, correct anemia, water retention, bone issues, seizures, electrolyte imbalance, etc.

 

B- Dialysis-This a procedure in which blood is purified by passing it through a filtration machine instead of kidneys. This removes the excess water, electrolytes, toxins, and metabolic end products from the blood. A patient would need dialysis as the Chronic kidney disease(CKD)condition advances to end-stage renal disease and the kidneys are no longer able to function. Dialysis works on the principle of diffusion of solutes and ultrafiltration of fluid across a semi-permeable membrane

 

There are 2 types of dialysis -

A- Haemodialysis -In this method of dialysis the blood is moved out of the body through a special cannula, filtered through a machine called a dialyzer, and returned to the body.

 

B- Peritoneal dialysis -Here, the filtration process is carried out inside the body by using the inner lining of your abdomen- peritoneum as a natural semipermeable membrane. A thin tube is inserted into your abdomen and a dialysis solution is introduced in the abdominal cavity. The waste and excess water get absorbed in the dialysis solution. This solution is then drained and discarded.

 

C- Kidney transplant- This is a surgery where a healthy kidney from a donor is placed in the body of the patient. This kidney now performs the function of filtering the blood. These patients do not require dialysis but have to take medicines that will prevent the body from rejecting the new organ.

 

Role of homeopathy in Chronic kidney disease(CKD) -

Homeopathy has some role to play in each stage of Chronic kidney disease. The medicines act as supportive, thus improving the patients symptomatically and improving their quality of life too. However early detection and treatment along with controlling the underlying factors is the key. Getting a Chronic kidney disease(CKD) diagnosis would cause a huge impact on the psyche of the patient leaving him sad, depressed, anxious. Homeopathic medicines also help to address disease-related anxiety. Few clinical studies were done on patients with chronic kidney disease(CKD) taking homeopathy suggests that it helps improve the serum creatinine levels and blood urea levels. Besides this, the patients also reported an improvement in the quality of life in terms of pain, swelling, sleep issues, mental well-being, etc. 

 

Medicines such as Apis Mel, Arsenic Alba, Eel serum, Anagallis, Apocynum, Cantharis, Lycopodium, Kali carb, Aurum Mur, Convularia, etc are useful.

 

These medicines are prescribed based on the symptoms that the patient is presenting with.

 

For more details about homeopathic treatment for chronic kidney disease(CKD), you may contact our doctors or chat with them.

 

Diet with Chronic kidney disease(CKD)-

Nutrition plays an important role in slowing down the progression of chronic kidney disease(CKD). In the initial stages where the patient does not have any symptoms, the kidney function is not much altered, a regular balanced diet is suggested. The patient is advised to keep away from refined food products, ready-to-eat food, bakery products, high-fat food, excessive sweets, smoking, alcohol, and carbonated drinks. 

 

As Chronic kidney disease(CKD) advances, kidney function starts to deteriorate, serum creatinine levels increase and GFR decreases, patient may be asked to follow strict diet restrictions. The strictness of these diet restrictions would depend on the grade of the Chronic kidney disease(CKD).

  1. Salt restriction 
  2. Restriction about fluid intake 
  3. Potassium restriction
  4. Phosphorus restriction
  5. Protein restriction

 

1-Salt restriction-Sodium is restricted in Chronic kidney disease(CKD) patients because their kidneys cannot excrete sodium. This can cause fluid accumulation in the body, an increase in blood pressure, and damage to the kidneys. A renal diet would restrict salt intake to up to 2300 mg/day. Besides this, all the other sources of salt such as pickles, papads, bakery products, biscuits, food with artificial preservatives, artificial sauces, etc are restricted.

 

2-Fluid restriction-As Chronic kidney disease(CKD) advances to end-stage renal disease the kidneys lose their ability to maintain the water balance in the body. This could lead to excess accumulation of fluid in the body causing edema. Depending on the stage of Chronic kidney disease(CKD) the doctor may restrict water intake. Besides water intake, there will also be a restriction on other fluids like tea, coffee, milk, soup, fruit juices, and fruits and vegetables containing an excess of water. 

 

3-Potassium restriction- The levels of potassium increase in the blood as the kidneys with impaired function are not able to excrete it out of the body. Along with it, certain medications and diets could also cause an increase in the total potassium content of the body leading to an emergency call as Hyperkalemia. The doctor will restrict potassium in the diet before the kidney failure sets in and the person is put on dialysis. The Potassium restrictions will depend on the eGFR of the patient. A low potassium diet would contain less than 2-3 g of potassium per day.

 

Bananas, melons, oranges, prunes, raisins, avocados, spinach, potatoes, tomatoes, beans, brown rice, etc have to be avoided if you are on a low potassium diet. 

 

4-Phosphorus restriction-As kidneys cannot excrete phosphorus, excess of same in the blood can attract calcium out from the bones leading to weak bones. The doctor would recommend phosphorus limitation from the onset of Chronic kidney disease(CKD) itself and these restrictions may get more severe as the condition advances. 

 

High phosphorus food includes items such as processed meat, processed cheese, and milk products, processed food/ ready to eat food, biscuits and bakery products, chocolates, carbonated drinks, wine, beer, etc 

 

5-Protein restriction-High protein diet especially the ones containing red meat can put a load on the filtering units of the kidneys, aggravating Chronic kidney disease(CKD). These patients are therefore advised to switch to a low protein diet. The protein allowed is 0.6 gm /kg of body weight per day.  

 

Managing kidney diseases

Getting diagnosed with Chronic kidney disease(CKD) is not an end to life, a person with chronic kidney disease(CKD) can live a fulfilling life with certain restrictions.

1-Achieve good control over the associated diseases like high BP or uncontrolled diabetes, take the medicines on time, monitor creatinine and GFR regularly, and follow up with the doctor regularly.

2-Chronic kidney disease(CKD) can put a lot of restrictions on the patient's diet. Discuss the concerns with the renal dietitian so that a diet plan is worked out around patients' preferred food choices or healthy alternatives are suggested.

3-Refrain from taking herbal medicines, supplements, and self medications

4- Chronic kidney disease(CKD) condition and diet restrictions could cause vitamin and mineral deficiencies. Speak to the doctor so that he prescribes Chronic kidney disease(CKD) specific health supplements. Regular supplements may contain ingredients that might not be needed or are harmful to the kidneys

5-Avoid smoking, tobacco, and Alcohol 

6- To remain fit, low-intensity exercises like walking, stretching, etc could be done under the supervision of a trained fitness trainer.

7-Meditate, spend time with loved ones, practice a hobby or learn new art, or join a support group will help people remain mentally happy and engaged.

 

Preventing Chronic kidney disease(CKD) 

If you have a family history of chronic kidney disease(CKD) or have underlying pathologies that could lead to Chronic kidney disease, below are some things that you may follow to protect your kidney function and to delay the onset of chronic kidney disease 

  1. Have good control over your diabetes, high blood pressure
  2. Maintain a healthy lifestyle. Eat healthily 
  3. Maintain healthy body weight 
  4. Avoid smoking, tobacco, and alcohol.
  5. If on any medications, take them on time, monitor your blood parameters regularly.
  6. Do not self medicate
  7. Avoid taking herbal supplements without doctors' consultation. 

 

 

 

 

 

 

 

 

 

  

  

 

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