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European Journal of Pediatrics

Erschienen in:

02.05.2016 | Review

The pathophysiology of monosymptomatic nocturnal enuresis with special emphasis on the circadian rhythm of renal physiology

verfasst von: L. Dossche, J. Vande Walle, C. Van Herzeele

Erschienen in: European Journal of Pediatrics | Ausgabe 6/2016

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Abstract

Nocturnal polyuria in monosymptomatic nocturnal enuresis (MNE) has so far mainly been attributed to a disturbed circadian rhythm of renal water handling. Low vasopressin levels overnight correlate with absent maximal concentrating activity, resulting in an increased nocturnal diuresis with low urinary osmolality. Therefore, treatment with desmopressin is a rational choice. Unfortunately, 20 to 60 % of children with monosymptomatic enuresis are desmopressin-resistant. There is increasing evidence that other disturbed circadian rhythms might play a role in nocturnal polyuria. This review focuses on renal aspects in the pathophysiology of nocturnal polyuria in MNE, with special emphasis on circadian rhythms. Articles related to renal circadian rhythms and enuresis were searched through the PubMed library with the goal of providing a concise review.

Conclusion: Nocturnal polyuria can only partially be explained by blunted circadian rhythm of vasopressin secretion. Other alterations in the intrinsic renal circadian clock system also seem to be involved, especially in desmopressin-resistant enuresis.

What is Known:

• Disturbance in the circadian rhythm of arginine vasopressin secretion is related to nocturnal polyuria in children with enuresis.

• Desmopressin is recommended as a treatment for monosymptomatic nocturnal enuresis, working as a vasopressin analogue acting on V2 receptors in the collecting ducts of the kidney.

What is New:

• Other renal circadian rhythms might play a role in nocturnal polyuria, especially in desmopressin-resistant case.

Aceto G, Penza R, Delvecchio M, Chiozza ML, Cimador M, Caione P (2004) Sodium fraction excretion rate in nocturnal enuresis correlates with nocturnal polyuria and osmolality. J Urol. doi:10.1097/01.ju.0000108420.89313.0f

Anderson RJ, Berl T, McDonald KD, Schrier RW (1975) Evidence for an in vivo antagonism between vasopressin and prostaglandin in the mammalian kidney. J Clin Invest 56:420–426. doi:10.1172/JCI108108 CrossRefPubMedPubMedCentral

Bader G, Nevéus T, Kruse S, Sillén U (2002) Sleep of primary enuretic children and controls. Sleep 25:573–577

Bael A, Sukhai RN (2012) Fysiologie en pathofysiologie van bedplassen. In: Groeneweg M, Vijverberg M, van Everdingen E, van der Deure J (eds) Incontinentie bij kinderen. Prelum, Houtem, pp 159–165

Borch L, Hagstroem S, Bower WF, Siggaard Rittig C, Rittig S (2013) Bladder and bowel dysfunction and the resolution of urinary incontinence with successful management of bowel symptoms in children. Acta Paediatr 102:e215–e220. doi:10.1111/apa.12158 CrossRefPubMed

Butler RJ, Golding J, Northstone K (2005) Nocturnal enuresis at 7.5 years old: prevalence and analysis of clinical signs. BJU Int 96:404–410. doi:10.1111/j.1464-410X.2005.05640.x CrossRefPubMed

De Bruyne E, Van Hoecke E, Van Gompel K, Verbeken S, Baeyens D, Hoebeke P, Vande Walle J (2009) Problem behavior, parental stress and enuresis. J Urol 182:2015–2020. doi:10.1016/j.juro.2009.05.102 CrossRefPubMed

De Bruyne P, De Guchtenaere A, Van Herzeele C, Raes A, Dehoorne J, Hoebeke P, Van Laecke E, Vande Walle J (2014) Pharmacokinetics of desmopressin administered as tablet and oral lyophilisate formulation in children with monosymptomatic nocturnal enuresis. Eur J Pediatr 173:223–228. doi:10.1007/s00431-013-2108-2 CrossRefPubMed

De Guchtenaere A, Raes A, Vande Walle C, Hoebeke P, Van Laecke E, Donckerwolcke R, Vande Walle J (2009) Evidence of partial anti-enuretic response related to poor pharmacodynamic effects of desmopressin nasal spray. J Urol 181:302–309. doi:10.1016/j.juro.2008.09.040, discussion 309CrossRefPubMed

10.

De Guchtenaere A, Vande Walle C, Van Sintjan P, Donckerwolcke R, Raes A, Dehoorne J, Van Laecke E, Hoebeke P, Vande Walle J (2007) Desmopressin resistant nocturnal polyuria may benefit from furosemide therapy administered in the morning. J Urol 178:2635–2639. doi:10.1016/j.juro.2007.08.026 CrossRefPubMed

11.

De Guchtenaere A, Vande Walle C, Van Sintjan P, Raes A, Donckerwolcke R, Van Laecke E, Hoebeke P, Vande Walle J (2007) Nocturnal polyuria is related to absent circadian rhythm of glomerular filtration rate. J Urol 178:2626–2629. doi:10.1016/j.juro.2007.08.028 CrossRefPubMed

12.

Dehoorne JL, Raes AM, van Laecke E, Hoebeke P, Vande Walle JG (2006) Desmopressin resistant nocturnal polyuria secondary to increased nocturnal osmotic excretion. J Urol 176:749–753. doi:10.1016/S0022-5347(06)00297-7 CrossRefPubMed

13.

Dhondt K, Baert E, Van Herzeele C, Raes A, Groen LA, Hoebeke P, Vande Walle J (2014) Sleep fragmentation and increased periodic limb movements are more common in children with nocturnal enuresis. Acta Paediatr 103:e268–e272. doi:10.1111/apa.12610 CrossRefPubMed

14.

Dhondt K, Raes A, Hoebeke P, Van Laecke E, Van Herzeele C, Vande Walle J (2009) Abnormal sleep architecture and refractory nocturnal enuresis. J Urol 182:1961–1965. doi:10.1016/j.juro.2009.05.103 CrossRefPubMed

15.

Dibner C, Schibler U, Albrecht U (2010) The mammalian circadian timing system: organization and coordination of central and peripheral clocks. Annu Rev Physiol 72:517–549. doi:10.1146/annurev-physiol-021909-135821 CrossRefPubMed

16.

Dossche L, Raes A, Hoebeke P, De Bruyne P, Vande Walle J (2016) Circadian rhythm of glomerular filtration and solute handling related to nocturnal enuresis. J Urol 195:162–167. doi:10.1016/j.juro.2015.07.079 CrossRefPubMed

17.

Dundaroz MR, Denli M, Uzun M, Aydin HI, Sarici SU, Yokusoglu M et al (2001) Analysis of heart rate variability in children with primary nocturnal enuresis. Int Urol Nephrol 32:393CrossRefPubMed

18.

Duong HA, Robles MS, Knutti D, Weitz CJ (2011) A molecular mechanism for circadian clock negative feedback. Science 332(80):1436–1439CrossRefPubMed

19.

Ecelbarger CA, Kim GH, Wade JB, Knepper MA (2001) Regulation of the abundance of renal sodium transporters and channels by vasopressin. Exp Neurol 171:227–234. doi:10.1006/exnr.2001.7775 CrossRefPubMed

20.

Englund M, Berg U (2000) Renal response to a protein load persists during long-term follow-up of children after renal transplantation. Transplantation 70:1342–1347CrossRefPubMed

21.

Firsov D, Bonny O (2010) Circadian regulation of renal function. Kidney Int 78:640–645. doi:10.1038/ki.2010.227 CrossRefPubMed

22.

Forsythe WI, Redmond A (1974) Enuresis and spontaneous cure rate. Arch Dis Child 49:259–263. doi:10.1136/adc.49.4.259 CrossRefPubMedPubMedCentral

23.

Fujiwara J, Kimura S, Tsukayama H, Nakahara S, Haibara S, Fujita M, Isobe N, Tamura K (2001) Evaluation of the autonomic nervous system function in children with primary monosymptomatic nocturnal enuresis. Scand J Urol Nephrol 35:350–356CrossRefPubMed

24.

Glazener CM, Evans JH (2002) Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev CD002112. doi: 10.1002/14651858.CD002112

25.

Goessaert A, Vande Walle J, Bosch JLHR, Hoebeke P, Everaert K (2016) Nocturnal polyuria—excess of nocturnal urine production, excess of definitions: influence on renal function profile. J Urol 195:670–676. doi:10.1016/j.juro.2015.09.076 CrossRefPubMed

26.

Gumz ML, Stow LR, Lynch IJ, Greenlee MM, Rudin A, Cain BD, Weaver DR, Wingo CS (2009) The circadian clock protein period 1 regulates expression of the renal epithelial sodium channel in mice. J Clin Invest 119:2423–2434. doi:10.1172/JCI36908.dehydrogenase CrossRefPubMedPubMedCentral

27.

Hagstroem S, Kamperis K, Rittig S, Rijkhoff NJM, Djurhuus JC (2004) Monosymptomatic nocturnal enuresis is associated with abnormal nocturnal bladder emptying. J Urol 171:2562–2566. doi:10.1097/01.ju.0000110882.31824.89 CrossRefPubMed

28.

Hansen MN, Rittig S, Siggaard C, Kamperis K, Hvistendahl G, Schaumburg HL, Schmidt F, Rawashdeh Y, Djurhuus JC (2001) Intra-individual variability in nighttime urine production and functional bladder capacity estimated by home recordings in patients with nocturnal enuresis. J Urol 166:2452–2455CrossRefPubMed

29.

Hjälmås K (1976) Micturition in infants and children with normal lower urinary tract. A urodynamic study. Scand J Urol Nephrol Suppl 37:1–106PubMed

30.

Hunsballe JM, Rittig S, Pedersen EB, Olesen OV, Djurhuus JC (1997) Single dose imipramine reduces nocturnal urine output in patients with nocturnal enuresis and nocturnal polyuria. J Urol 158:830–836. doi:10.1016/S0022-5347(01)64330-1 CrossRefPubMed

31.

Hurwitz S, Cohen RJ, Williams GH (2004) Diurnal variation of aldosterone and plasma renin activity: timing relation to melatonin and cortisol and consistency after prolonged bed rest. J Appl Physiol 96:1406–1414. doi:10.1152/japplphysiol.00611.2003 CrossRefPubMed

32.

Kamperis K, Hagstroem S, Radvanska E, Rittig S, Djurhuus JC (2010) Excess diuresis and natriuresis during acute sleep deprivation in healthy adults. Am J Physiol Ren Physiol 299:F404–F411. doi:10.1152/ajprenal.00126.2010 CrossRef

33.

Kamperis K, Hansen MN, Hagstroem S, Hvistendahl G, Djurhuus JC, Rittig S (2004) The circadian rhythm of urine production, and urinary vasopressin and prostaglandin E2 excretion in healthy children. J Urol 171:2571–2575. doi:10.1097/01.ju.0000110421.71910.c0 CrossRefPubMed

34.

Kamperis K, Rittig S, Bower WF, Djurhuus JC (2012) Effect of indomethacin on desmopressin resistant nocturnal polyuria and nocturnal enuresis. J Urol 188:1915–1922. doi:10.1016/j.juro.2012.07.019 CrossRefPubMed

35.

Kamperis K, Rittig S, Jørgensen KA, Djurhuus JC (2006) Nocturnal polyuria in monosymptomatic nocturnal enuresis refractory to desmopressin treatment. Am J Physiol Ren Physiol 291:F1232–F1240. doi:10.1152/ajprenal.00134.2006 CrossRef

36.

Kamperis K, Rittig S, Radvanska E, Jørgensen KA, Djurhuus JC (2008) The effect of desmopressin on renal water and solute handling in desmopressin resistant monosymptomatic nocturnal enuresis. J Urol 180:707–714. doi:10.1016/j.juro.2008.04.047 CrossRefPubMed

37.

Koff SA (1983) Estimating bladder capacity in children. Urology 21:248. doi:10.1016/0090-4295(83)90079-1 CrossRefPubMed

38.

Krieger J, Laks L, Wilcox I, Grunstein R, Costas L, McDougall J, Sullivan C (1989) Atrial natriuretic peptide release during sleep in patients with obstructive sleep apnoea before and during treatment with nasal continuous positive airway pressure. Clin Sci 77:407–411CrossRefPubMed

39.

Kruse A, Mahler B, Rittig S, Djurhuus JC (2009) Increased nocturnal blood pressure in enuretic children with polyuria. J Urol 182:1954–1960. doi:10.1016/j.juro.2009.04.079 CrossRefPubMed

40.

Kuznetsova AA, Natochin YV, Papayan AV (1998) Osmoregulatory function of the kidney in enuretic children. Scand J Urol Nephrol 32:132–137. doi:10.1080/003655998750014521 CrossRefPubMed

41.

Kuznetsova AA, Shakhmatova EI, Prutskova NP, Natochin YV (2000) Possible role of prostaglandins in pathogenesis of nocturnal enuresis in children. Scand J Urol Nephrol 34:27–31CrossRefPubMed

42.

Mahler B, Kamperis K, Schroeder M, Frokiaer J, Djurhuus JC, Rittig S (2012) Sleep deprivation induces excess diuresis and natriuresis in healthy children. AJP Ren Physiol 302:F236–F243. doi:10.1152/ajprenal.00283.2011 CrossRef

43.

Mills JN, Stanbury S (1952) Persistent 24-hour renal excretory rhythm on a 12-hour cycle of activity. J Physiol 117:22–37PubMedPubMedCentral

44.

Moore-Ede M (1986) Physiology of the circadian timing system: predictive versus reactive homeostasis. Am J Physiol 250:R737–R752PubMed

45.

Natochin YV, Kuznetsova AA (1999) Defect of osmoregulatory renal function in nocturnal enuresis. Scand J Urol Nephrol Suppl 202:40–44PubMed

46.

Nevéus T (2008) The new International Children’s Continence Society’s terminology for the paediatric lower urinary tract—why it has been set up and why we should use it. Pediatr Nephrol 23:1931–1932. doi:10.1007/s00467-008-0865-3 CrossRefPubMed

47.

Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, Jørgensen TM, Rittig S, Walle JV, Yeung C-K, Djurhuus JC (2006) The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society. J Urol 176:314–324. doi:10.1016/S0022-5347(06)00305-3 CrossRefPubMed

48.

Nicco C, Wittner M, DiStefano A, Jounier S, Bankir L, Bouby N (2001) Chronic exposure to vasopressin upregulates ENaC and sodium transport in the rat renal collecting duct and lung. Hypertension 38:1143–1149. doi:10.1161/hy1001.092641 CrossRefPubMed

49.

Nørgaard JP, Pedersen EBDJ (1985) Diurnal anti-diuretic-hormone levels in enuretics. J Urol 134:1029–1031PubMed

50.

Okamura H, Doi M, Fustin J-M, Yamaguchi Y, Matsuo M (2010) Mammalian circadian clock system: molecular mechanisms for pharmaceutical and medical sciences. Adv Drug Deliv Rev 62:876–884. doi:10.1016/j.addr.2010.06.004 CrossRefPubMed

51.

Pons M, Forpomès O, Espagnet SCJ (1996) Relationship between circadian changes in renal hemodynamics and circadian changes in urinary glycosaminoglycan excretion in normal rats. Chronobiol Int 13:349–358CrossRefPubMed

52.

Raes A, Dehoorne J, Hoebeke P, Van Laecke E, Donckerwolcke R, Vande Walle J (2006) Abnormal circadian rhythm of diuresis or nocturnal polyuria in a subgroup of children with enuresis and hypercalciuria is related to increased sodium retention during daytime. J Urol 176:1147–1151. doi:10.1016/j.juro.2006.04.054 CrossRefPubMed

53.

Raes A, Dossche L, Hertegonne N, Nuytemans L, Hoebeke P, Van Laecke E, Donckerwolcke R, Walle JV (2010) Hypercalciuria is related to osmolar excretion in children with nocturnal enuresis. J Urol 183:297–301. doi:10.1016/j.juro.2009.08.175 CrossRefPubMed

54.

Richards J, Gumz ML (2012) Advances in understanding the peripheral circadian clocks. FASEB J 26:3602–3613. doi:10.1096/fj.12-203554 CrossRefPubMedPubMedCentral

55.

Rittig S, Schaumburg H, Schmidt F, Hunsballe JM, Hansen AF, Kirk J, Vestergaard P, Djurhuus J (1997) Long-term home studies of water balance in patients with nocturnal enuresis. Scand J Urol Nephrol Suppl 183(183):25–26PubMed

56.

Rittig S, Kamperis K, Siggaard C, Hagstroem S, Djurhuus JC (2010) Age related nocturnal urine volume and maximum voided volume in healthy children: reappraisal of International Children’s Continence Society definitions. J Urol 183:1561–1567. doi:10.1016/j.juro.2009.12.046 CrossRefPubMed

57.

Rittig S, Knudsen UB, Norgaard JP, Gregersen H, Pedersen EB, Djurhuus JC (1991) Diurnal variation of plasma atrial natriuretic peptide in normals and patients with enuresis nocturna. Scand J Clin Lab Invest 51:209–217CrossRefPubMed

58.

Rittig S, Knudsen UB, Norgaard JP, Pedersen EB, Djurhuus JC (1989) Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. Am J Physiol 256:F664–F671PubMed

59.

Rittig S, Matthiesen TB, Pedersen EB, Djurhuus JC (1999) Sodium regulating hormones in enuresis. Scand J Urol Nephrol Suppl 202:45–46PubMed

60.

Rittig S, Matthiesen TB, Pedersen EB, Djurhuus JC (2006) Circadian variation of angiotensin II and aldosterone in nocturnal enuresis: relationship to arterial blood pressure and urine output. J Urol 176:774–780. doi:10.1016/S0022-5347(06)00594-5 CrossRefPubMed

61.

Rittig S, Schaumburg HL, Siggaard C, Schmidt F, Djurhuus JC (2008) The circadian defect in plasma vasopressin and urine output is related to desmopressin response and enuresis status in children with nocturnal enuresis. J Urol 179:2389–2395. doi:10.1016/j.juro.2008.01.171 CrossRefPubMed

62.

Smith E (1861) Health and disease as influenced by the daily, seasonal, and other cyclical changes in the human system

63.

Starfield B (1967) Functional bladder capacity in enuretic and non enuretic children. J Pediatr 70:777–781CrossRefPubMed

64.

Tauris LH, Andersen RF, Kamperis K, Hagstroem S, Rittig S (2012) Reduced anti-diuretic response to desmopressin during wet nights in patients with monosymptomatic nocturnal enuresis. J Pediatr Urol 8:285–290. doi:10.1016/j.jpurol.2011.03.018 CrossRefPubMed

65.

Tokonami N, Mordasini D, Pradervand S, Centeno G, Jouffe C, Maillard M, Bonny O, Gachon F, Gomez RA, Sequeira-Lopez MLS, Firsov D (2014) Local renal circadian clocks control fluid-electrolyte homeostasis and BP. J Am Soc Nephrol 25:1430–1439. doi:10.1681/ASN.2013060641 CrossRefPubMedPubMedCentral

66.

Valenti G, Laera A, Pace G, Aceto G, Lospalluti ML, Penza R, Selvaggi FP, Chiozza ML, Svelto M (2000) Urinary aquaporin 2 and calciuria correlate with the severity of enuresis in children. J Am Soc Nephrol 11:1873–1881PubMed

67.

Valenti G, Laera A, Gouraud S, Pace G, Aceto G, Penza R, Selvaggi FP, Svelto M (2002) Low-calcium diet in hypercalciuric enuretic children restores AQP2 excretion and improves clinical symptoms. Am J Physiol Ren Physiol 283:F895–F903. doi:10.1152/ajprenal.00354.2001 CrossRef

68.

Van Herzeele C, Alova I, Evans J, Eggert P, Lottmann H, Nørgaard JP, Vande Walle J (2009) Poor compliance with primary nocturnal enuresis therapy may contribute to insufficient desmopressin response. J Urol 182:2045–2049. doi:10.1016/j.juro.2009.06.001 CrossRefPubMed

69.

Van Herzeele C, De Bruyne P, De Bruyne E, Vande Walle J (2015) Challenging factors for enuresis treatment: psychological problems and non-adherence. J Pediatr Urol 11:1–6. doi:10.1016/j.jpurol.2015.04.035 CrossRef

70.

Van Herzeele C, Dhondt K, Roels SP, Raes A, Hoebeke P, Groen L-A, Vande Walle J (2016) Desmopressin (melt) therapy in children with monosymptomatic nocturnal enuresis and nocturnal polyuria results in improved neuropsychological functioning and sleep. Pediatr Nephrol. doi:10.1007/s00467-016-3351-3

71.

Voogel AJ, Koopman MG, Hart AAM, Van Montfrans GA, Arisz L (2001) Circadian rhythms in systemic hemodynamics and renal function in healthy subjects and patients with nephrotic syndrome. Kidney Int 59:1873–1880CrossRefPubMed

72.

Vande Walle J, Rittig S, Bauer S, Eggert P, Marschall-Kehrel D, Tekgul S (2012) Practical consensus guidelines for the management of enuresis. Eur J Pediatr 171:971–983. doi:10.1007/s00431-012-1687-7 CrossRefPubMedPubMedCentral

73.

Vande Walle J, Vande Walle C, Van Sintjan P, De Guchtenaere A, Raes A, Donckerwolcke R, Van Laecke E, Mauel R, Dehoorne J, Van Hoyweghen E, Hoebeke P (2007) Nocturnal polyuria is related to 24-hour diuresis and osmotic excretion in an enuresis population referred to a tertiary center. J Urol 178:2630–2634. doi:10.1016/j.juro.2007.08.029 CrossRefPubMed

74.

Vande Walle JGJ, Bogaert GA, Mattsson S, Schurmans T, Hoebeke P, Deboe V, Norgaard JP (2006) A new fast-melting oral formulation of desmopressin: a pharmacodynamic study in children with primary nocturnal enuresis. BJU Int 97:603–609. doi:10.1111/j.1464-410X.2006.05999.x CrossRefPubMed

75.

Yakıncı C, Müngen B, Durmaz Y, Balbay D, Karabıber H (1997) Autonomic nervous system functions in children with nocturnal enuresis. Brain Dev 19:485–487. doi:10.1016/S0387-7604(97)00069-7 CrossRefPubMed

76.

Yeung CK, Chiu HN, Sit FKY (1999) Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol 162:1049–1055CrossRefPubMed

77.

Yeung CK, Diao M, Sreedhar B (2008) Cortical arousal in children with severe enuresis. N Engl J Med 358:2414–2415. doi:10.1056/NEJMc0706528 CrossRefPubMed

78.

Yeung CK, Sihoe JDY, Sit FKY, Bower W, Sreedhar B, Lau J (2004) Characteristics of primary nocturnal enuresis in adults: an epidemiological study. BJU Int 93:341–345. doi:10.1111/j.1464-410X.2003.04612.x CrossRefPubMed

79.

Yeung CK, Sit FKY, To LKC, Chiu HN, Sihoe JDY, Lee E, Wong C (2002) Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis. BJU Int 90:302–307CrossRefPubMed

80.

Yeung CK, Sreedhar B, Sihoe JDY, Sit FKY, Lau J (2006) Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int 97:1069–1073. doi:10.1111/j.1464-410X.2006.06074.x CrossRefPubMed

Titel: The pathophysiology of monosymptomatic nocturnal enuresis with special emphasis on the circadian rhythm of renal physiology
verfasst von: L. Dossche
J. Vande Walle
C. Van Herzeele
Publikationsdatum: 02.05.2016
Verlag: Springer Berlin Heidelberg
Erschienen in: European Journal of Pediatrics / Ausgabe 6/2016
Print ISSN: 0340-6199
Elektronische ISSN: 1432-1076
DOI: https://doi.org/10.1007/s00431-016-2729-3

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The pathophysiology of monosymptomatic nocturnal enuresis with special emphasis on the circadian rhythm of renal physiology

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