What Medical Administrators Have to Find out about Dialysis Facility Water Administration

What Medical Directors Need to Know about Dialysis Facility Water Management
January 28, 2021 0 Comments


Be Engaged

It may be disconcerting to medical administrators once they notice that, as a Facilities for Medicare and Medicaid Companies (CMS) situation for protection (CFC), “the medical director is answerable for the security and high quality of the water used for dialysis remedies” (1). Though this response is comprehensible, with schooling and coaching, all medical administrators can present the suitable management essential to hold their clinic’s water therapy system operating easily and supply a basis for optimum affected person care by the supply of purified water for dialysis. To this finish, knowledgeable engagement from the medical director round water high quality is important. The medical director shapes the power perspective towards water high quality, and he/she has each the authority and duty to make the difficulty a excessive precedence (2).

Verifying environment friendly operation of the water therapy system ought to be an integral element of every clinic’s high quality evaluation and efficiency enchancment program (QAPI). Reaching the mandatory CMS CFC for dialysis water high quality includes reaching thresholds for each chemical purity (Desk 1) and microbiologic and endotoxin purity (Desk 2), all of which require proficient operation of the water therapy system and vigilant monitoring. QAPI conferences are convened repeatedly and attended by the medical director and the clinic’s interdisciplinary group, in order that amongst facility, personnel, and affected person care subjects, outcomes of product water chemical analyses, dialysate and product water laboratory testing, and microbiologic testing of the water distribution system will be reviewed. Within the context of steady enchancment and CFC compliance (Part 494.40 Situation: Water and Dialysate High quality [1]), the medical director and the power biomedical technician ought to assessment the operation and testing data of the water therapy system recorded within the upkeep and monitoring log. Over and above remaining compliant on this regard, a month-to-month QAPI assembly can be the suitable discussion board for threat analyses and evaluation of water high quality enchancment initiatives. As needed, the medical director ought to drive root-cause analyses to determine indicators of water high quality issues, consider the related dangers, and decide mitigation within the context of current QAPI processes.

Desk 1.

Consuming water requirements versus dialysis water requirements

Desk 2.

Testing thresholds for microbiologic contaminants

Know Your Supply Water

With help from the power’s biomedical technician or one other particular person with operational understanding of the dialysis facility, the medical director ought to confirm from the place the clinic’s water is derived. The standard and traits of the power’s supply water may have an effect on the operation of the power’s water therapy system and information planning efforts, particularly in instances the place the supply water could turn into compromised, which will be the case in a pure catastrophe. As a finest apply, medical administrators ought to confirm that the scientific group communicates straight with the suppliers of supply water no much less often than yearly to advise suppliers of the water’s meant use and the necessity for advance discover when there could also be a disruption in provision of supply water. As well as, advance warning is required within the case of pressing or scheduled supply water disinfection by hyperchlorination or permanganate therapy. Equally, any medical director of an acute-care facility positioned on the campus of a medical middle should take into account that the medical middle may additional deal with supply water to be used within the hospital setting. In such situations, sustaining shut communication with hospital operations is important to know when the plant supervisor could also be treating the hospital water, in order that the dialysis facility doesn’t draw hospital water throughout occasions of disinfection or therapy (3).

The Environmental Safety Company (EPA) has minimal requirements for municipal ingesting water (4); nevertheless, the EPA requirements for acceptable ranges of contaminants are many occasions better than these permissible for water utilized in dialysis therapy (Desk 1) (3,5). The 2004 Affiliation for the Development of Medical Instrumentation (AAMI) RD52 thresholds for acceptable ranges of inorganic chemical contaminants in purified dialysis water have been adopted by the CMS (Desk 1) (1,5). Accordingly, chemical testing ought to be carried out for facility-purified product water and supply water yearly or as required by native regulation. Extra testing must also be thought-about when system monitoring exhibits a decline in product water high quality or after repairs to the water therapy system that might have an effect on product water high quality, reminiscent of when reverse osmosis membranes are changed. Medical administrators ought to know that, because the unique publication of RD52, the AAMI has up to date its suggestions for tolerable bacterial and endotoxin concentrations in product water and dialysate with out modifying its threshold for inorganic contaminants (Desk 2). Regardless of these modifications, the CMS continues to make use of the AAMI RD52 guideline to outline CFC compliance. Nevertheless, it’s attainable that, sooner or later, the CMS could replace its place, though at the moment there isn’t any definitive timeline for any modifications.

Understanding the traits of the power’s supply water will permit the medical director, biomedical technician, and scientific group to create a sensible and efficient high quality assurance plan within the occasion that the supply water is compromised due to pure or artifical disasters (Desk 3) (6–8). Appropriately, any high quality assurance plan ought to determine backup water sources for emergencies (9). Plans that embrace the usage of faucet water or dechlorinated faucet water are possible solely with “proof the supply water has been discovered secure for such use (i.e., has ranges beneath the AAMI accepted limits of aluminum, copper, chloramines, fluoride, nitrate, sulfate, zinc, and different contaminants recognized to be poisonous to dialysis sufferers)” (2). The standard assurance preparations of each dialysis clinic ought to define each a plan of motion and a plan of correction for anticipated failures in supply water availability in addition to inside the water therapy system itself.

Desk 3.

Count on the surprising: High quality assurance planning

Perceive the Water Therapy System

Water therapy programs are designed to supply dialysis-quality water, however the varieties of elements used can differ considerably in keeping with the native water high quality–outlined pretreatment wants, the amount of product water wanted by the power, and the chosen water therapy know-how. The water system elements depicted listed below are typical however under no circumstances signify the totality of these used. There is no such thing as a one dimension suits all water therapy system, as a result of water therapy steps are routinely tailor-made to the native water and the contaminants that should be eliminated.

The dialysis facility water therapy system is normally positioned in a devoted, secured, and access-controlled water room that has been fitted appropriately to supply supply water, drains, and electrical energy wanted to assist the system. The water room ought to be properly organized, uncluttered, clear, and dry. There ought to be no water leaks or disagreeable odors. The system ought to have correct up-to-date signage and movement diagrams indicating the route of water motion and on and off valve positions, in addition to a log ebook itemizing system elements with fields for recording gadget stress readings, water movement readings, and purity measures made by the power group (Determine 1). Every system element ought to be labeled (1,2), and element producers ought to be recognized on every label, together with contact data and a supply for the producer’s suggestions for proper use (Determine 1).

A properly saved water room is orderly with labeled therapy system elements. (A) A properly saved water room. Proven is {a photograph} of a dialysis facility water room. The area is immaculate, and system elements are correctly labeled. (B) Acceptable labeling for a water therapy system element. This mixing worth label describes the gadget and refers operators on to clinic reference supplies for upkeep and troubleshooting. BMT, biomedical technician facility; CWP, clear water merchandise; FA, facility administrator; RO, reverse osmosis.

” data-icon-position=”” data-hide-link-title=”0″>Figure 1.

Determine 1.

A properly saved water room is orderly with labeled therapy system elements. (A) A properly saved water room. Proven is {a photograph} of a dialysis facility water room. The area is immaculate, and system elements are correctly labeled. (B) Acceptable labeling for a water therapy system element. This mixing worth label describes the gadget and refers operators on to clinic reference supplies for upkeep and troubleshooting. BMT, biomedical technician facility; CWP, clear water merchandise; FA, facility administrator; RO, reverse osmosis.

Medical administrators ought to absolutely acquaint themselves with the elements of their water therapy system and acknowledge the looks of a easily operating water room. Moreover, he/she ought to examine the water room each time attainable; if circumstances aren’t as they need to be, immediate follow-up with the power’s scientific leaders and biomedical technician is crucial. To determine probably harmful circumstances or failure of water therapy system elements (Desk 3), the medical director ought to by no means hesitate to query circumstances that appear uncommon.


Water therapy system supply water will should be pretreated earlier than it may be purified. Pretreatment consists of a number of steps, together with temperature adjustment, backflow prevention, pressurization, filtration of grit and sediment, water softening, and carbon filtration for dechlorination (Determine 2).

The water therapy system. This schematic delineates a water therapy system with oblique product water distribution (i.e., a holding tank). PG, stress gauge; RO, reverse osmosis; SP, sampling port.

” data-icon-position=”” data-hide-link-title=”0″>Figure 2.

Determine 2.

The water therapy system. This schematic delineates a water therapy system with oblique product water distribution (i.e., a holding tank). PG, stress gauge; RO, reverse osmosis; SP, sampling port.

Sometimes, step one in pretreatment is temperature adjustment. This step happens within the mixing valve, the place heated and unheated supply water is combined to a desired temperature, usually between 60°F and 85°F. It is very important have a correctly sized water heater to supply ample sizzling water that can accommodate the clinic’s demand. The ability group ought to monitor and report the output temperature a minimum of each day, which ought to stay comparatively fixed inside a 2–3°F vary (Determine 2, Desk 4).

Desk 4.

Monitoring duties for a clinic water therapy system

After the supply water temperature has been adjusted by the mixing worth, the system ought to be fitted with a backflow or reverse movement prevention gadget. This water therapy system element retains the water flowing within the route of the purification system and by no means backward towards the water supply. There’s a stress gauge on both facet of it in addition to a filter, which can turn into clogged. Strain variations >30 psi throughout the gadget counsel an obstruction of the filter that requires upkeep (Determine 2, Desk 4).

After the backflow prevention gadget is the booster pump, which pressurizes the system. As its identify implies, the aim of the booster pump is to maintain water transferring by the water therapy system, optimizing system efficiency and purification. A stress swap turns the booster pump on and off as wanted. When system stress falls beneath the required threshold (the set level), the pump will mechanically activate; it’s going to flip off once more when the system stress is satisfactorily restored. Set factors will differ in keeping with the power’s water want and are distinctive to the system. The biomedical technician ought to periodically examine the booster pump to make sure that it’s making use of the suitable stress (Determine 2, Desk 4).

The subsequent step in pretreatment is filtration of grit and sediment from the feed water (Determine 2, Desk 4). That is achieved by the depth multimedia filter. This gadget removes massive suspended particles from the water and prevents clogging of downstream water system elements, together with the reverse osmosis unit. In the beginning of every day, a facility group member ought to guarantee there’s a <15-psi distinction throughout the filter. The depth multimedia gadget ought to be outfitted with a backflush function programmed to happen mechanically exterior the conventional hours of facility operation.

After bigger particulate matter has been decreased, the feed water is prepared for water softening (Determine 2, Desk 4). The resin media contained within the water softener have a excessive affinity for calcium and magnesium cations, that are recognized to make water laborious. Feed water containing calcium and magnesium can type scale deposits downstream on the reverse osmosis membrane, fouling the membrane (Desk 3) and decreasing the standard of purified product water. The calcium- and magnesium-binding capability of the water softener resin ought to be regenerated on a routine foundation by washing with a concentrated sodium chloride resolution or brine. Positioned adjoining to the water softener is a brine tank containing salt pellets and water, making a supersaturated salt resolution used for softener regeneration. After a media backwashing step, brine is drawn from the tank into the water softener. Through the regeneration course of, the calcium and magnesium are displaced from the softener resin media by aggressive inhibition by sodium ions within the concentrated brine. Afterward, residual salt resolution is rinsed out of the water softener. Mechanically regenerating water softeners ought to be outfitted with a lockout gadget to stop the regeneration course of from occurring throughout affected person remedies. The clock and timer integral to the water softener ought to be learn initially of every therapy day, in contrast with actual time, and adjusted as needed (Determine 2, Desk 4), as a result of energy failures may presumably reset media regeneration to happen throughout affected person therapy hours. Strain gauges on the inlet and outlet of the water softener ought to be fitted to watch stress drop (Δ), and softener water samples ought to be examined on the finish of the use-day to confirm that applicable capability is maintained. Fast postsoftener water take a look at outcomes exhibiting <1 grain per gallon or 17 mg/L hardness point out ample water softening. The timer-setting verification, Δ-pressure, and hardness take a look at outcomes ought to be documented each day within the upkeep log (Determine 2, Desk 4).

The subsequent step in water pretreatment is carbon filtration, which is used to take away the chlorine and/or chloramines added to municipal water programs. This course of usually includes use of a pair of filter tanks positioned in collection that comprise granular-activated carbon (GAC). The primary carbon filter tank, known as the first or employee tank, should have ample capability to supply a adequate quantity of GAC media to dechlorinate the feed water given the water calls for of the dialysis facility. Frequent testing of the feed water flowing from the first tank outlet is important to confirm that whole chlorine ranges stay ≤0.1 components per million (PPM). Thus, the power group ought to take a look at whole chlorine on the whole chlorine pattern take a look at port between the 2 tanks a number of occasions a day throughout clinic operation: at the start of every use day, earlier than the beginning of affected person therapy, and at least each 4 hours all through every therapy day (Determine 2, Desk 4).

The carbon filtration course of is important: chlorine and chloramine publicity can hurt sufferers (Desk 3). Furthermore, chlorine compounds are reactive and may injury the reverse osmosis membrane, the water therapy system element most important for purification. As a result of this step is so important, a secondary polisher GAC filter tank is positioned instantly downstream from the first employee tank and after the full chlorine pattern take a look at port. Within the occasion that the employee filter has a chlorine breakthrough, this collection design gives dechlorination redundancy. Like the first employee filter, the secondary polisher filter is satisfactorily sized to guard the sufferers from chlorine and chloramine publicity and in addition fitted with a pattern take a look at port. Ought to the employee filter have a chlorine breakthrough, the power group should use the pattern take a look at port after the secondary polisher GAC filter to confirm whole chlorine ranges. If whole chlorine ranges are ≤0.1 PPM threshold, affected person dialysis remedies can proceed. Nevertheless, after any incidence of chlorine breakthrough from the first tank, it’s endorsed that the power group monitor the full chlorine degree on the pattern port after the secondary GAC filter tank each half-hour till affected person therapy is accomplished, the first GAC filter tank is changed, or the first filter GAC media are changed (10).

The final element usually thought-about a part of the pretreatment system is the water purification system prefilter (Determine 2, Desk 4). This particulate filter (or filters) is positioned within the water therapy system after the secondary GAC filter tank and simply earlier than the feed water inlet to the water purification system. The prefilter will catch residual carbon fines (small carbon particles), resin beads, and different particles within the pretreated feed water that may in any other case foul or injury the downstream water purification system. Sometimes, the prefilter could have a pore dimension starting from 1 to five μm. Two gauges monitor the inlet and outlet pressures throughout the filter, and subsequently, the operator can monitor filter stress drop. The ability group should report all filter modifications within the water therapy system upkeep log. The reverse osmosis prefilter is often modified after the cleansing and/or disinfection procedures are accomplished or each time stress drop readings point out that filter alternative is required.


With the pretreatment steps accomplished, the feed water is prepared for purification. The commonest technique used to purify water for hemodialysis therapy is reverse osmosis. (Determine 2, Desk 4). The reverse osmosis gadget is a self-contained unit that makes use of a high-pressure pump and a semipermeable membrane to purify water (Determine 2, Desk 4). On this purification course of, pretreated water pressurized by the reverse osmosis high-pressure pump is compelled to movement throughout and thru the reverse osmosis membrane, which is particularly designed to reject or not permit passage of most dissolved inorganic parts, reminiscent of ions of metals, salts, and chemical compounds in addition to natural supplies, reminiscent of micro organism, viruses, and endotoxin. A correctly functioning membrane will reject organics with >200 D in addition to 95%–99% of ion particles, that are concentrated and redirected to empty. Machine efficiency is decided by proportion rejection (>90%) and the conductivity of ultimate product water (measured in micro-Siemens per 1 cm or by the full dissolved solids in milligrams per liter or PPM), each of that are measured repeatedly by an integral monitor set in keeping with the producer’s suggestions. The gadget ought to show these information and have working audible and visible alarms that, when high quality thresholds aren’t met, will be heard on the reverse osmosis gadget and within the affected person care space. The reverse osmosis gadget wants periodic upkeep administered by certified service technicians strictly adhering to the producer’s directions. All upkeep procedures ought to be precisely recorded.

A much less frequent method for water purification is deionization (DI). Utilizing DI as a major water purification technique is strongly discouraged (2), but when used as an extra purification step (i.e., for sprucing) or in emergency circumstances, DI requires fail-safe programs to divert or block product water movement when product water resistivity drops to <1 MΩ cm, precluding affected person publicity to product water exterior accepted high quality limits. DI could also be used to shine product water after reverse osmosis or as a standby technique when a reverse osmosis system fails. DI water resistivity readings ought to be measured repeatedly utilizing an applicable temperature-compensated monitor that can cease product water movement to the distribution system and supply each audible and visible alarms within the water therapy room and affected person care space when product water high quality drops beneath the appropriate vary. Operator documentation of DI standing and efficiency ought to be recorded within the water system log earlier than beginning affected person therapy on a given use-day; further checks ought to be documented on the finish of a use-day (2).


The final step in dialysis water preparation is distribution of purified water to the factors of use required to make dialysate resolution for affected person therapy (Determine 2, Desk 4).

The 2 frequent varieties of distribution programs utilized in dialysis clinics are generally known as direct and oblique feed programs. With direct feed water distribution programs, pressurized by the reverse osmosis high-pressure pump, the purified water exits the reverse osmosis system and passes by an endotoxin filter earlier than continuing to the distribution loop designed to supply purified water to the varied factors of use on the dialysis flooring. The unused purified water is returned by the loop to the pump inlet of the direct feed reverse osmosis system to be recycled by the reverse osmosis pump and membrane(s). With oblique water distribution programs, the purified water exiting the reverse osmosis system enters a specifically designed holding tank outfitted with water-level management gadgets. These gadgets work together with the reverse osmosis system, turning it on and off as wanted and preserving the suitable water degree within the holding tank, in order that the tank doesn’t go dry or overfill. The purified water within the holding tank is repressurized by the distribution booster pump, which directs the purified water from the tank by an endotoxin filter earlier than continuing out to the distribution loop, offering purified water to the varied factors of use on the dialysis therapy flooring. Oblique purified water distribution programs return unused purified water again to the holding tank. The distribution loop and holding tank shouldn’t be fabricated from supplies that might contribute chemical compounds to the purified water, together with tubing and plumbing fabricated from aluminum, copper, lead, or zinc.

Ultraviolet (UV) irradiation is usually used to assist management bacterial proliferation in dialysis water distribution programs (each direct and oblique varieties). It is necessary that any UV gadget used for bacterial management be sized to permit applicable irradiation contact time on the most anticipated water movement of the water distribution system and be adopted by an endotoxin filter. UV gadgets should even be monitored and serviced as required by the producer to stop sublethal UV dose supply. Failure to dimension and preserve a UV gadget can result in proliferation of UV-resistant micro organism within the water distribution system.

Microbial Surveillance

Micro organism and Endotoxin

The water therapy and distribution programs are designed to incorporate pattern ports to permit water assortment. Collected samples ought to be despatched to an accredited laboratory (preferentially one that makes a speciality of dialysis water testing) for bacterial cultures and endotoxin-level examination (11); pattern assortment ought to at all times happen earlier than disinfection of the water therapy system, distribution loop, or dialysis machines (2). The ability group ought to draw water samples from the primary and final shops inside the distribution loop and different shops used to supply purified water for dilution of focus and different purposes, reminiscent of dialyzer reprocessing, utilizing the sampling and testing methodologies specified within the RD52 doc (5). The CMS RD52 requirements for action-level contamination inside dialysate and purified water are 50 CFU/ml and 1 endotoxin unit/ml for bacterial and endotoxin contamination, respectively (Desk 2) (5). Vital “actions could also be to repeat cultures, notably when one in a set of cultures was above the motion restrict, or to disinfect the system and repeat cultures at a number of websites” (2). Assessments exhibiting micro organism and endotoxin concentrations in extra of the utmost allowable ranges (<200 CFU/ml and <2.0 endotoxin unit/ml) may end up in discontinuation of dialysis therapy and quick remediation as deemed most applicable by the medical director.

The RD52 doc comprises a map outlining the suitable pattern assortment and culturing strategies (5). All new dialysis water purification and distribution programs ought to be examined weekly for bacterial development and endotoxin till a sample of compliance with RD52 is proven. After some weeks persistently reaching the required CMC CFC high quality requirements, testing will be carried out month-to-month; nevertheless, extra frequent testing might be needed when cultures from a number of websites are repeatedly constructive (2). Utilizing the take a look at outcomes to find out the place the system contamination could be is crucial; isolation and disinfection of the potential level of contamination are required accordingly. An evaluation of bacterial contamination information over time can also be really helpful to infer whether or not contamination by microorganisms, each above and beneath the motion degree, could have modified in contrast with prior testing. Extra testing would even be needed on clinician request ought to sufferers expertise sickness or pyrogenic response throughout or after dialysis.


The pipes and storage tanks of water distribution programs are in danger for microbiologic contamination, and, subsequently, want common disinfection. All routine and pressing disinfection actions ought to be recorded within the water therapy system upkeep log and repeatedly reviewed as a CFC and finest apply. The final technique ought to be for the biomedical technician to maintain a strict schedule designed to keep away from the proliferation of organisms in purified water somewhat than disinfect for micro organism after an action-level contamination take a look at outcome. There are tips for medical administrators to contemplate on this regard: the RD52 doc comprises a map outlining the mandatory steps in keeping with the chosen disinfection technique (5).

The strategies used to supply the scheduled routine disinfection of the water purification gear and distribution loops will rely, partly, on the kind of system and materials being disinfected. The suitable disinfection course of for a selected system ought to be really helpful and/or accepted by the producer of the system. Peracetic acid–sort chemical compounds are generally used to disinfect most programs; in some instances, sodium hypochlorite (bleach) or ozone could be really helpful to be used. Sizzling water disinfection is turning into extra generally used to supply disinfection in numerous programs. Within the absence of unacceptable micro organism and endotoxin outcomes, distribution gear ought to be disinfected no much less often than each 4 weeks.

Microorganisms and particularly, Gram-negative micro organism remaining in pipes exterior the hours of dialysis operation will proliferate and cling to moist surfaces, doubtless forming communities of microorganisms known as biofilms (5). Actually, biofilm could also be current in water storage and distribution programs even when micro organism and endotoxin take a look at outcomes are low. Nevertheless, inconsistent and erratic micro organism testing outcomes may counsel the presence of bacteria-shedding biofilm within the water storage or distribution system (2). Microorganisms detected by testing signify solely these organisms suspended in water; it might take weeks to detect any biofilm downside. It’s also necessary to acknowledge that cultures quantifying planktonic micro organism signify a small fraction of organisms launched from gathered biofilm inside the system. When bacterial contamination persists regardless of frequent and aggressive disinfection, it might be needed to find out if biofilm is a trigger. In such situations, use of other disinfection strategies and even alternative of kit could also be required to remediate biofilm.

Know the Medical Significance of Water System Failure

The wellness of sufferers on dialysis begins with assembly the minimal requirements for dialysis water high quality (Desk 1). Chemical and steel contaminants which can be secure in ingesting water for ingestion by wholesome sufferers aren’t secure in sufferers on hemodialysis who’re uncovered to roughly 400 L dialysis water per therapy 3 times per week (12).

The associations between sickness and dialysis water contaminants are properly described (Desk 5), starting from generally benign (pruritus) to lethal (encephalopathy) (13). Chloramine is broadly recognized to trigger hemolysis, anemia, and demise in sufferers on dialysis (14). Nevertheless, excessive concentrations of different minerals will also be deadly: eight sufferers had deadly encephalopathy proven to be related to the addition of aluminum compounds to municipal water, leading to a 3- to 16-mg load of aluminum with every dialysis therapy (15); the outbreak of sickness was stopped with the addition of a DI step within the dialysis water purification course of. Extra just lately, dialysis water contaminants have been implicated within the lack of response to erythropoietin of sufferers on hemodialysis. Fluck et al. (16) printed that, over time, chloramine ranges in water had been inversely related to imply hemoglobin and straight related to imply erythropoietin dosing in sufferers on hemodialysis. Rahmati et al. (17) printed that, below secure erythropoietin dosing, sufferers’ imply hemoglobin ranges elevated after the addition of a brand new reverse osmosis filter. Masuhashi and Yoshioka (18) confirmed an analogous outcome. When further endotoxin was faraway from dialysis water, imply affected person hematocrit was elevated, whereas imply erythropoietin dosing was decreased within the 5 months after the elimination. Cumulatively, these outcomes counsel that endotoxin contaminants in dialysis water at concentrations beneath these inflicting scientific signs, reminiscent of fever, could scale back sufferers’ response to erythropoietin remedy, presumably by power inflammatory stimulus. These research name into query whether or not the minimal purity requirements at the moment utilized by the CMS for dialysis water might be raised to probably enhance scientific outcomes in sufferers. Knowledge reminiscent of these ought to encourage medical administrators to suppose past the minimal necessities utilized by the CMS.

Desk 5.

Contaminants poisonous to sufferers on dialysis

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