Live donor nephrectomy side: Is it implicated in urologic complications among lady donors during their post-donation pregnancies?

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Live donor nephrectomy side: Is it implicated in urologic complications among lady donors during their post-donation pregnancies?

https://doi.org/10.21203/rs.3.rs-2218606/v2

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Introduction:

Our center policy is to promote right nephrectomy for pre-menopausal live donor ladies. This is based on the traditional belief that urologic complications of post-donation pregnancies would be more frequent among lady donors with a solitary right (compared to left) kidney. Studies that support or dismiss our policy are lacking. Therefore, we conducted this study.

Methods:

100 ladies who had post-donation pregnancy were included. They underwent an updated clinical, laboratory and ultrasound assessment. They were classified into two groups: right and left nephrectomy groups. Both groups were compared relative to pre- and post-donation data as well as urologic complications during or after post-donation pregnancies and current kidney function.

Results:

Right nephrectomy was carried-out for 60 donors (60%). Post-donation acute pyelonephritis was not reported in either group. Unexpectedly, lower urinary tract infection during post-donation pregnancy occurred among 16.7% of ladies of the right nephrectomy group compared to 12.5% in the left nephrectomy group (p: non-significant).

Conclusion:

Despite that the endeavor to retrieve the right rather than the left kidney among lady donors could give them the benefit of doubt in regard to possible urological complications during their subsequent pregnancies, this policy is likely an overdoing practice. Larger-scale studies are needed.

Health sciences/Nephrology

Health sciences/Urology

Live kidney donor

Pregnancy

‎Nephrectomy side

Urinary complication.

Kidney transplantation is the best currently available treatment modality for patients with end stage kidney disease. In Egypt, the only source of transplanted kidneys is live donors in view of absent cadaveric program. At our center, ladies constituted 1734 (55.5%) out of 3126 donors over the period between 1976 and 2020 [1].

Throughout this period, our center policy concerning ladies who donate a kidney during their child-bearing period has been to prefer right donor nephrectomy whenever possible. The left kidney has been only retrieved if it has an anatomical abnormality or its split function on isotope study is significantly lower compared to the right kidney (provided that it is still suitable for transplantation), or if the right kidney has multiple renal arteries making its retrieval a complex surgery. This policy has been adopted despite the preference of our transplant surgeons to retrieve the left kidney as transplantation mostly occurs on the right side of the recipient and it is, therefore, technically easier to transplant the left kidney. The rationale behind this policy is the belief that if pregnancy occurs after donation, female kidney donors with a solitary right kidney will be subjected to more urologic complications compared to those with a solitary left kidney. This belief is based on the well-known information that hydronephrosis during pregnancy is more pronounced on the right side [2]. Nevertheless, such practice may create an extra-pressure on the transplant team especially in ‎the ‎context of the rapidly growing minimally invasive donor nephrectomy technique ‎in ‎which right nephrectomy is generally not preferred [3].

As we know that there is no robust evidence to support or dismiss our left-kidney sparing policy among female kidney donors who may get pregnant after donation and because studies in this area are lacking, we conducted this study in order to assess the impact of laterality of donor nephrectomy among ladies on the urologic complications during their post-donation pregnancy and subsequent kidney function after pregnancy.

This retrospective cohort study was conducted at the urology and nephrology center, Mansoura University, Egypt. It included 100 ladies who donated a kidney over the period between 1976 and 2020 at our center and had one or more ‎ post-donation pregnancy after donation. They were either picked up during their regular visit to our post-donation clinic or retrieved after a phone call for those who lost follow up. Ladies who donated their kidneys after menopause or those who donated their kidneys during the child-bearing period but didn't get pregnant thereafter were excluded from the study.

The included ladies underwent clinical, laboratory and ultrasound assessment and their files were retrieved in order to obtain obstetric and urologic data. They were classified according to the side of donor nephrectomy into right and left donor nephrectomy groups. A special sheet designed for the study was filled in.

In terms of the relation of our ladies to their recipients, ‎51 (51%) were sisters, 44 (44%) were wives and 5 (5%) were mothers.‎ The accepted age of potential kidney donors at our center is 21–60 years [1]. While the lower age limit has been strict, parents above the age of 60 years are increasingly accepted as a donor for their offsprings if they are completely healthy and are the only available donor.

Lower urinary tract infection was diagnosed if there are symptoms suggestive of acute ‎cystitis including dysuria, frequency and urgency without fever or flank pain. Acute pyelonephritis was diagnosed if there are flank pain and fever/chills with or without symptoms of acute cystitis.

All methods were carried out in accordance with relevant guidelines and regulations.

Data of the ladies included in the study were exported to SPSS program. Continuous data were expressed as mean ± standard deviation and were compared using T-test ‎ while nominal data were expressed as numbers (percentages) and were compared using and Chi-square test.

Right nephrectomy was carried-out in 60 of ‎ out of the studied 100 donors (60%). Table 1 shows that both right and left donor nephrectomy groups were comparable in terms of pre-donation characteristics including age, number of pre-donation pregnancies and kidney function. Apart from family history of renal failure (the recipient), medical history was irrelevant in both donor groups except for bronchial asthma and mild hypertension in one lady of the right and left nephrectomy groups respectively.

Table 1

Pre-donation characteristics of right and left donor nephrectomy groups
	Right donor nephrectomy group (N = 60)	Left donor nephrectomy group (N = 40)	P value
Age at donation in years	27.85 ± 5.73	29.25 ± 4.57	0.198
Number of pregnancies before donation M ± SD Median (min.-max.) Frequency ‎None One ‎Two ‎Three ‎Four ‎Five ‎Eight	‎1.83 ± 1.45‎ 2 (0–5) ‎15 (25%)‎ ‎10 (16.7%)‎ ‎16 (26.7%)‎ ‎10 (16.7%)‎ ‎7 (11.6%)‎ ‎2 (3.3%)‎ 0 (0%)	‎2.3 ± 1.83‎ 2 (0–8) ‎8 (20%)‎ ‎6 (15%)‎ ‎10 (25%)‎ ‎5 (12.5%)‎ ‎7 (17.5%)‎ ‎3 (7.5%)‎ 1 (2.5%)	0.159 0.16 0.741
Lower UT symptoms during pre-donation pregnancies No Yes	56 (93.3%) 4 (6.7%)	38 (95%) 2 (5%)	0.73
Relevant medical history before donation None Bronchial asthma Mild hypertension	59 (98.4%) 1 (1.6%) 0 (0%)	39 (97.5%) 0 (0%) 1 (2.5%)	0.338
Pre-donation surgical history Tonsillectomy Caesarean section Cholecystectomy Appendectomy Disc prolapse	1 (1.6%) 10 (16.6%) 1‎ (1.6%)‎ 1 ‎(1.6%)‎ 0 (0%)	1 (2.5%) 3 (7.5%) 0 (0%) 0 (0%) 1 (2.5%)	0.771 0.182 0.412 0.412 0.412
Systolic blood pressure before donation (mm Hg)	117.50 ± 8.36	118.75 ± 8.53	0.469
Diastolic blood pressure before donation (mm Hg)	77.50 ± 10.02	79.25 ± 8.59	0.366
Body mass index before donation (kg/m²) 18.5–24.9 25-29.9 ≥ 30	15 (25%) 29 (48.3%) 16 (26.7%)	11 (27.5%) 25 (62.5%) 4 (10%)	0.117
Fasting blood sugar before donation (mg/dl)	‎88.97 ± 9.36	‎87.36 ± 8.01	0.380
Total cholesterol before donation (mg/dl)	‎177.15 ± 33.39	‎170.8 ± 30.18	‎0.721‎
Serum bilirubin before donation (mg/dl)	‎0.57 ± 0.31	‎0.56 ± 0.27	0.823
Hemoglobin before donation (g%)	‎12.06 ± 0.96	‎12.26 ± 0.86	0.589
Serum creatinine (mg/dl) before donation (M ± SD)	0.73 ± 0.14	0.68 ± 0.16	0.08

Table 2 shows post-donation data of both groups. The number of post-donation pregnancies was comparable in both groups. Almost half of the ladies in both groups got more than one pregnancy after donation. Right and left nephrectomy group ladies had a total of 108 and 62 post-donation pregnancies respectively. Post-donation acute pyelonephritis was not reported in either group. Among both groups, 40% had lower urinary tract infection during more than one pregnancy after donation. A total of 23 lower urinary tract infections occurred in both groups during a total number of 170 post-donation pregnancies. Unexpectedly, lower urinary tract infection during post-donation pregnancy occurred among 16.7% of individuals of the right nephrectomy group compared to 12.5% in the left nephrectomy group yet this difference was statistically insignificant (p = 0.776). Furthermore, one of the right nephrectomy group ladies developed post-donation ureteral obstruction with DJ insertion and subsequent successful stone extraction and resolution of obstructive uropathy and another lady developed end stage renal disease 21 years after donation due to a non-urologic etiology (likely related to toxemia of pregnancy) and has been unfortunately maintained on hemodialysis since 16 years despite that her donated kidney to her sister is currently perfect. Among all ladies in both groups, the current urinary tract ultrasound doesn’t show obstructive uropathy of the remaining kidney. Updated urine analysis showed asymptomatic pyuria in two ladies of the right nephrectomy group. Serum creatinine at last follow-up was higher, yet statistically insignificant, among the right nephrectomy group ladies. After exclusion of end stage renal disease lady in the right nephrectomy group, serum creatinine at last follow-up becomes slightly lower in the right (0.75 ± 0.11 mg/dl) compared to the left (‎0.78 ± 0.12 mg/dl‎) nephrectomy group yet without statistical significance (p = 0.163).

Table 2

Post-donation characteristics of right and left donor nephrectomy groups
	Right donor nephrectomy group (N = 60)	Left donor nephrectomy group (N = 40)	P value
Age at last follow up in years	41.45 ± 7.95	42.98 ± 9.46	0.39
Post-donation follow up period (years)	13.60 ± 8.98	13.73 ± 9.10	0.95
Number of pregnancies after donation M ± SD Median (min.-max.) Frequency - One - Two - Three - Four - Five - Seven	‎1.8 ± 1.25‎ 1 (1–7) 34 (56.7%) 15 (25%) 5 (8.3%) 3 (5%) 2 (3.3%) 1 (1.7%)	‎1.55 ± 0.71‎ 1 (1–3) 23 (57.5%) 12 (30%) 5 (12.5%) 0 (0%) 0 (0%) 0 (0%)	0.25 0.26 0.46
Lower UT symptoms during post-donation pregnancies No Yes	50 (83.3%) 10 (16.7%)	35 (87.5%) 5 (12.5%)	0.413
Number of post-donation pregnancies with Lower UT symptoms One pregnancy Two pregnancies Three pregnancies	6 (60%) 2 (20%) 2 (20%)	3 (60%) 2 (40%) 0 (0%)	0.47
Acute pyelonephritis during post-donation pregnancies No Yes	60 (100%) 0	40 (100%) 0
Post-donation medical diseases Hypertension Diabetes mellitus Ischemic heart disease Bronchial asthma Hyperthyroidism ESRD Cancer Breast Bladder	15 (25%) 6 (10%) 3 (5%) 1 (1.6%) 1 (1.6%) 1 (1.6%) 1 (1.6%) 0	9 (22.5%) 5 (12.5%) 0 0 0 0 0 1 (2.5%)	0.675 0.695 0.151 0.412 0.412 0.412 0.338
Systolic blood pressure at last follow up (mm Hg)	121.83 ± 13.21	122.50 ± 14.63	0.813
Diastolic blood pressure at last follow up (mm Hg)	78.17 ± 10.97	77.75 ± 11.87	0.857
Body mass index at last follow up (kg/m²) 18.5–24.9 25-29.9 ≥ 30	3 (5%) 16 (26.7%) 41 (68.3%)	4 (10%) 9 (22.5%) 21 (67.5%)	0.599
Fasting blood sugar at last follow up (mg/dl)	‎95.08 ± 20.93	‎94.78 ± 18.72	0.94
Total cholesterol at last follow up (mg/dl)	‎192.13 ± 34.89	‎192.55 ± 36.67	‎0.954
Serum bilirubin at last follow up (mg/dl)	‎0.54 ± 0.26	‎0.60 ± 0.27	0.267
Hemoglobin at last follow up (g%)	‎12.06 ± 0.96	‎12.26 ± 0.86	0.285
Serum creatinine (mg/dl) at last follow up (M ± SD)	0.93 ± 1.45	0.78 ± 0.12	0.502
Urine analysis at last follow up Free Non-nephrotic proteinuria Non-nephrotic proteinuria + microscopic hematuria Asymptomatic pyuria	54 (90%) 2 (3.33%) 2 ‎(3.33%)‎ 2 (‎3.33%)‎	35 (87.5%) 3 (7.5%) 2 (5%) 0 (0%)	0.503

To the best of our knowledge, this is the first study that evaluates the impact of donor nephrectomy laterality on future pregnancy as well as future kidney function among donors. In our study, we investigated the hypothesized benefit of right over left donor nephrectomy from the donor perspective. Conversely, the potential advantage of left over right donor nephrectomy was previously studied; mainly from the recipient perspective. Traditionally, surgeons prefer to transplant the left kidney as it has a longer renal vein. In an analysis of OPTN/UNOS database that included about 60,000 live-donor transplants, right donor nephrectomy recipients had significantly higher conversion from laparoscopic to open donor nephrectomy, delayed graft function and graft thrombosis as a cause of graft failure, and significantly lower graft survival. Nevertheless, the authors concluded that as these differences are small, the choice of nephrectomy side should be primarily dictated by surgical team preference and experience [4]. A meta-analysis of laparoscopic donor nephrectomy that included 15 studies and more than 3000 kidney transplants conversely showed that left laparoscopic donor nephrectomy was associated with significantly longer operative time, more blood loss and more donor intraoperative complications. However, both sides were comparable relative to the rate of conversion to open nephrectomy, delayed graft function, recipient and donor post-operative complications and one year graft survival and recommended left donor nephrectomy whenever possible due to longer renal vein making surgery easier [5].‎ It is interesting that the majority of donor nephrectomy in both studies were left sided (86.1% and 78% respectively) reflecting the general trend of surgeons to perform left donor nephrectomy. On the other hand, retrieval of the available data of our all transplant series showed that left donor nephrectomy was performed in only 1403 (60.4%) out of 2323 kidney transplants. The relatively lower percentage of left donor nephrectomy among our series compared to the previous two large studies may be attributed to our preference to perform right nephrectomy among female donors who have the potential to get pregnant after donation and to our routine use of donor renal isotope scan as a contributing tool in choosing the side of donor nephrectomy [6].

Interestingly, an abstract published in 2017 explored the impact of donor nephrectomy side on long-term donor outcome in terms of suprarenal function and suggested that left (compared to right) donor nephrectomy may predispose live donors to future adrenal insufficiency with more fatigue and poorer quality of life [6]. In addition, there was a report on a young lady who got pregnant shortly after undergoing left donor nephrectomy with subsequent acute kidney injury late during pregnancy presumably due to pregnancy-related right hydronephrosis [8]. More than half of pregnant ladies develop hydronephrosis late during pregnancy due to both mechanical and hormonal causes [9]. Hydronephrosis is more pronounced on the right side due to different anatomy of the right compared to the left ureter making the right ureter more liable to compression as it crosses the iliac artery at the pelvic brim and crossed by the right ovarian vein, compression by the dextrorotated uterus and crossing right ovarian vein and protection of the left ureter by the gas-filled sigmoid colon [10, 11] .However, laterality difference in terms of urologic complications during pregnancy is rarely evaluated [8, 11]. In our study, right and left donor nephrectomy group ladies were comparable in terms of urologic complications during post-donation pregnancy as well as blood pressure, kidney function, urine analysis and ultrasound findings at last follow up contrary to our expectation that donors with a solitary right kidney would be more ‎liable to urologic complications of pregnancy and subsequent impact on kidney function. Nevertheless, our results could be supported by extrapolation from studies of the general population that did not show an increased prevalence of urinary tract infection [12] or stone kidney disease [13–15] during pregnancy despite the known anatomic and physiologic effects of pregnancy on the urinary system. In addition, donors included in our study didn’t have a periodic follow up renal ultrasound throughout pregnancy and we, therefore, are not confident whether they experienced hydronephrosis and whether those with a solitary right (compared to left) kidney had a significantly higher prevalence and/or degree of hydronephrosis during their post-donation pregnancy. Moreover, no other specific studies among kidney donors or even among single-kidney ladies are available for comparison.

The overall prevalence of lower urinary tract infection among our ladies was 13.5% during their post-donation pregnancies (23 infections in 170 pregnancies); much higher than that reported among other ladies. Although the prevalence of symptomatic urinary tract infection among ladies of the general population during pregnancy is not exactly known, it is suggested to be 1-2.3% [9, 16, 17]. This difference may be attributed to the method of diagnosis being mainly on clinical basis among our ladies. It may also reflect a real increase in prevalence of urinary tract infection in post-kidney donation pregnancy. Moreover, it is likely that socioeconomic standard might affect the occurrence of urinary tract infection among our pregnant ladies as our reported prevalence was closer to that (8.9%) reported in a cohort of more than 4000 pregnant ladies from Bangladesh [18]. This could explain the wide range of prevalence (3–35%) in a study which included pregnant ladies from five continents [19].

Minimally invasive donor nephrectomy is gaining more popularity. Laparoscopic donor nephrectomy has become the standard of care in some centers. Nevertheless, left nephrectomy is more preferred for laparoscopic compared to open nephrectomy due to technical aspects [3]. At our center, laparoscopic donor nephrectomy has been exclusively performed on the left side [20]. Our results may increase the use of laparoscopic nephrectomy among our lady donors with possible improvement of post-donation morbidity and hospitalization period.

In conclusion, we could not observe a notable difference in terms of pregnancy-related urinary complications or long-term outcome among ladies who have a remaining right kidney after kidney donation. Despite that the endeavor to retrieve the right rather than the left kidney among lady ‎kidney donors could give them the benefit of the doubt in regard to possible urological ‎complications during their subsequent pregnancies, this policy is likely an overdoing ‎practice and should only be adopted when it doesn’t jeopardize the decision based on any other factor which could affect either recipient and donor outcome. Larger-scale studies are needed to support this conclusion.‎

Ethical approval:

Ethical approval was waived by the local Ethics Committee of Urology and Nephrology Center, Mansoura University in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

Freely-given, written informed consent to participate in the research studies conducted by Urology and Nephrology Center was obtained from the recipients and donors before transplantation who are also free to get back in this consent at any time after transplantation. We also declare that no kidneys were donated by prisoners and all the kidney transplant surgeries were conducted under the supervision of the national committee of organ transplantation and Mansoura University. As regard the vulnerable groups, female donors who donated their kidneys were relatives to the recipients and we exhausted ourselves to make sure that they are free from coercion and donated their kidneys by their free well giving them the chance to stop at any time before the surgery.

Data Availability Statement:

All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.

Conflict of Interest: All authors declared no conflict of interest.

Funding resources: Not funded.

Authors^˒contributions:

Ahmed Farouk Donia: Data analysis and interpretation and writing the article. Eman Elrefaie: Participated in data collection. Ayman Fathi Refaie: Revision of the final version to be published and Providing a clinical experience to the work described. Moatasem Elsayed Ghoneim: Participated in data collection. Yasser Osman: Revision of the final version to be published and providing a clinical experience to the work described. Bedeir Ali-El-Dein: Revision of the final version to be published and Providing a clinical experience to the work described.

Acknowledgements

We are very grateful to all nephrology staff in Urology and Nephrology center, Mansoura University who helped over the past 40 years in delivering high quality nephrology service to our patients. We really could not have done this without their help, thank you all.

-Donia AF, Fouda MA, Ghoneim ME, Refaie AF, Ali-El-Dein B. The previously common post-kidney transplant Kaposi sarcoma has become non-existent for a decade: an Egyptian experience. J Cancer Res Clin Oncol. 2021;147(5):1493–1498.
-White J, Ory J, Lantz Powers AG, Ordon M, Kroft J, Cox A. Urological issues in pregnancy: A review for urologists. Can Urol Assoc J 2020;14(10):352–357.
-Musquera M, Peri L, D'Anna M, Ajami T, Ribal MJ, Vilaseca A, et al. Outcomes after 20 years of experience in minimally invasive living-donor nephrectomy. World J Urol. 2022 Mar;40(3):807–813.
-Khalil A, Mujtaba MA, Taber TE, Yaqub MS, Goggins W, Powelson J, et al. Trends and outcomes in right vs. left living donor nephrectomy: an analysis of the OPTN/UNOS database of donor and recipient outcomes–should we be doing more right-sided nephrectomies?. Clin Transplant. 2016;30(2):145–153.
-Wang K, Zhang P, Xu X, Fan M. Right Versus Left Laparoscopic Living-Donor Nephrectomy: A Meta-Analysis. Exp Clin Transplant 2015;13(3):214–26.
-Shokeir AA, Gad HM, el-Diasty T. Role of radioisotope renal scans in the choice of nephrectomy side in live kidney donors. J Urol 2003;170(2 Pt 1):373–6.
-Schachtner, Thomas, Reinke, Petra. Left-Sided Donor Nephrectomy Predisposes Living Kidney Donors to Latent Adrenal Insufficiency with Symptoms of Fatigue and Inferior Quality of Life. Transplantation 2017;101 - Issue - p S71 doi: 10.1097/01.tp.0000525090.17858.77
-Kıran H, Kıran G, Arıkan D, M Yüzbaşıoğlu 2, M Bakacak 1, Ö Ercan, et al. Is the Left Kidney the Right One for Kidney Donation in Women Planning on Future Pregnancy?. Int J Organ Transplant Med 2015;6(4):182–184.
-White J, Ory J, Lantz Powers AG, Ordon M, Kroft J, Cox A. Urological issues in pregnancy: A review for urologists. Can Urol Assoc J 2020;14(10):352–357.
-Bres-Niewada E. Ureteral obstruction in pregnancy - The “Stone Mountain” for the urologist. Cent Eur J Urol 2017;70:101–2.
-Valovska M-TI, Pais VM. Contemporary best practice urolithiasis in pregnancy. Therapeutic Advances in Urology 2018; 10(4):127–138.
-Hooton TM, Gupta K. Urinary tract infections and asymptomatic bacteriuria in pregnancy. In: UpToDate, Calderwood SB, Lockwood CJ, (Eds), UpToDate, Waltham, MA. (Accessed on May 20, 2022).
-Tangren JS, Powe CE, Ecker J, Bramham K, Ankers E, Karumanchi SA., & Thadhani, R. et al. Metabolic and Hypertensive Complications of Pregnancy in Women with Nephrolithiasis. Clin J Am Soc Nephrol 2018;13(4):612–619.
-Thakur APS, Sharma V, Ramasamy V, Choudhary A, Patel P, Singh S, et al. Management of ureteric stone in pregnancy: a review. Afr J Urol 26, 60 (2020).
-Kirubarajan A, Taheri C, Yau M, Aggarwal R, Lam A, Golda N, et al. Incidence of kidney stones in pregnancy and associations with adverse obstetrical outcomes: a systematic review and meta-analysis of 4.7 million pregnancies. J Matern Fetal Neonatal Med 2021;1–9.
-Mazor-Dray E, Levy A, Schlaeffer F, Sheiner E. Maternal urinary tract infection: is it independently associated with adverse pregnancy outcome?. J Matern Fetal Neonatal Med. 2009;22(2):124–128.
-Harris RE, Gilstrap LC 3rd. Cystitis during pregnancy: a distinct clinical entity. Obstet Gynecol. 1981;57(5):578–580.
-Lee AC, Mullany LC, Koffi AK, et al. Urinary tract infections in pregnancy in a rural population of Bangladesh: population-based prevalence, risk factors, etiology, and antibiotic resistance. BMC Pregnancy Childbirth 2019;20(1):1.
-Gilbert NM, O'Brien VP, Hultgren S, Macones G, Lewis WG, Lewis AL. Urinary tract infection as a preventable cause of pregnancy complications: opportunities, challenges, and a global call to action. Glob Adv Health Med 2013;2(5):59–69.
-Mansour A, Elnahas A, Nasr E, Elshabrawy A, Ibrahim E, Shoma A, et al. Laparoscopic Left Donor Nephrectomy: Contemporary Technique, Tips and Tricks. Videourology 2020; 34(5).

No competing interests reported.

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Live donor nephrectomy side: Is it implicated in urologic complications among lady donors during their post-donation pregnancies?

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Introduction

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References

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