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Gomez M, Bañon-Maneus E, Arias-Guillén M, Fontseré N, Broseta JJ, Ojeda R, Maduell F. Distinct Solute Removal Patterns by Similar Surface High-Flux Membranes in Haemodiafiltration: The Adsorption Point of View. Blood Purif 2021; 51:38-46. [PMID: 33789268 DOI: 10.1159/000514936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Haemodialysis (HD) allow depuration of uraemic toxins by diffusion, convection, and adsorption. Online haemodiafiltration (HDF) treatments add high convection to enhance removal. There are no prior studies on the relationship between convection and adsorption in HD membranes. The possible benefits conferred by intrinsic adsorption on protein-bound uraemic toxins (PBUTs) removal are unknown. METHODS Twenty-two patients underwent their second 3-days per week HD sessions with randomly selected haemodialysers (polysulfone, polymethylmethacrylate, cellulose triacetate, and polyamide copolymer) in high-flux HD and HDF. Blood samples were taken at the beginning and at the end of the treatment to assess the reduction ratio (RR) in a wide range of molecular weight uraemic toxins. A mid-range removal score (GRS) was also calculated. An elution protocol was implemented to quantify the amount of adsorbed mass (Mads) for each molecule in every dialyser. RESULTS All synthetic membranes achieved higher RR for all toxins when used in HDF, specially the polysulfone haemodialyser, resulting in a GRS = 0.66 ± 0.06 (p < 0.001 vs. cellulose triacetate and polyamide membranes). Adsorption was slightly enhanced by convection for all membranes. The polymethylmethacrylate membrane showed expected substantial adsorption of β2-microglobulin (MadsHDF = 3.5 ± 2.1 mg vs. MadsHD = 2.1 ± 0.9 mg, p = 0.511), whereas total protein adsorption was pronounced in the cellulose triacetate membrane (MadsHDF = 427.2 ± 207.9 mg vs. MadsHD = 274.7 ± 138.3 mg, p = 0.586) without enhanced PBUT removal. DISCUSSION/CONCLUSION Convection improves removal and slightly increases adsorption. Adsorbed proteins do not lead to enhanced PBUTs depuration and limit membrane efficiency due to fouling. Selection of the correct membrane for convective therapies is mandatory to optimize removal efficiency.
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Affiliation(s)
- Miquel Gomez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundacio Clínic per la Recerca Biomedica (FCRB), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elisenda Bañon-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundacio Clínic per la Recerca Biomedica (FCRB), Hospital Clínic de Barcelona, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | | | - Néstor Fontseré
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - José Jesús Broseta
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Raquel Ojeda
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Francisco Maduell
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
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Masakane I, Sakurai K. Current approaches to middle molecule removal: room for innovation. Nephrol Dial Transplant 2018; 33:iii12-iii21. [PMID: 30281129 PMCID: PMC6168896 DOI: 10.1093/ndt/gfy224] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 06/13/2018] [Indexed: 01/31/2023] Open
Abstract
Aggressive removal of middle molecules or larger low-molecular-weight proteins (LMWPs) has been a growing concern following studies on their harmful effects on the mortality and morbidity of chronic dialysis patients. To remove larger LMWPs and some protein-bound uremic toxins (PBUTs), high- and medium-cutoff (HCOs and MCOs, respectively) membranes, convective therapy and protein adsorptive membranes are available. When we use HCO or MCO membranes for convective therapy, we have to take care to avoid massive albumin leakage during a dialysis session. Convection volume is an important element to increase middle molecule removal; however, a larger convection volume has a risk of larger leakage of albumin. Predilution hemodiafiltration is a useful measurement to increase larger LMWPs without massive albumin leakage. β2-microglobulin (B2M), α1-microglobulin (A1M) and albumin leakage during a dialysis session are useful parameters for assessing middle-molecule removal. Reduction ratios of B2M >80% and of A1M >35% are favorable to improve severe dialysis-related symptoms. The efficacy of middle molecule removal should be evaluated in comparison with clinical outcomes, mortality, morbidity and the improvement of dialysis-related symptoms. Recently some dialysis-related symptoms such as sleep disturbance, skin itchiness and dialysis hypotension have been recognized as good surrogate makers for mortality. Further studies to evaluate the relationship between middle molecule or PBUTs removal and the improvement of patient symptoms should be performed in well-designed randomized controlled trials.
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Affiliation(s)
- Ikuto Masakane
- Department of Nephrology, Yabuki Hospital, Yamagata, Japan
| | - Kenji Sakurai
- Hashimoto Clinic, Dialysis Center, Sagamihara, Japan
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Kohlová M, Amorim CG, Araújo A, Santos-Silva A, Solich P, Montenegro MCBSM. The biocompatibility and bioactivity of hemodialysis membranes: their impact in end-stage renal disease. J Artif Organs 2018; 22:14-28. [DOI: 10.1007/s10047-018-1059-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/08/2018] [Indexed: 12/15/2022]
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Hudier L, Decaux O, Haddj-Elmrabet A, Lino M, Mandart L, Siohan P, Renaudineau E, Sawadogo T, Lamy De La Chapelle T, Oger E, Bridoux F, Vigneau C. Intensive haemodialysis using PMMA dialyser does not increase renal response rate in multiple myeloma patients with acute kidney injury. Clin Kidney J 2017; 11:230-235. [PMID: 29644064 PMCID: PMC5887381 DOI: 10.1093/ckj/sfx079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/19/2017] [Indexed: 02/02/2023] Open
Abstract
Background Intensive haemodialysis (IHD) in addition to bortezomib-based chemotherapy might be efficient to rapidly decrease serum immunoglobulin-free light chains removal in patients with multiple myeloma (MM) and to improve renal prognosis and survival. Methods The aim of this retrospective multi-centre study was to compare the efficacy (renal recovery rate) of IHD and of standard haemodialysis (SHD) in patients with MM and dialysis-dependent acute kidney injury (AKI), concomitantly treated with bortezomib-based chemotherapy. Results We selected 41 patients with MM and dialysis-dependent AKI, most likely due to myeloma cast nephropathy (MCN), and who were treated in eight French hospitals between January 2007 and June 2011. Patients were classified in two groups according to dialysis regimen: IHD [n = 21, with a mean of 11.3 dialysis sessions all with poly(methyl methacrylate) (PMMA) membranes for 13.2 days] and SHD (n = 20 patients, mostly three times per week, 31% with PMMA membrane). The main outcome was dialysis-independence at 3 months. At 3 months, 15 patients could stop dialysis: 8 (38.1%) in the IHD and 7 (35%) in the SHD group (P = 1). Moreover, 14 (56%) of the 25 patients who did show haematological response and only one of the 16 patients who did not were dialysis-independent (P = 0.002) at 3 months. Conclusions The results of this retrospective study did not show any clear renal benefit of IHD in patients with MM and MCN compared with SHD. Conversely, they underline the importance of the haematological response to chemotherapy for the renal response and patient prognosis.
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Affiliation(s)
- Laurent Hudier
- Centre hospitalier Broussais, Service de Néphrologie-Hémodialyse, Saint-Malo, France
| | - Olivier Decaux
- CHU Rennes, Service de Médecine Interne, Rennes, France
- CHU Rennes, Service de Néphrologie, Rennes, France
- CHU de Nantes, Service de Néphrologie et d'Immunologie Clinique, Nantes, France
- Centre Hospitalier Bretagne Atlantique, Service de Néphrologie-Hémodialyse, Vannes, France
- Centre Hospitalier de Cornouaille, Service de Néphrologie-Hémodialyse, Quimper, France
- Centre Hospitalier de Bretagne Sud, Service de Néphrologie-Hémodialyse, Lorient, France
- CHU Rennes, Service d'Hématologie clinique, Rennes, France
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
- Université de Rennes 1, UMR CNRS 6290 IGDR, 35042 Rennes, France
| | | | - Marie Lino
- CHU de Nantes, Service de Néphrologie et d'Immunologie Clinique, Nantes, France
| | - Lise Mandart
- Centre Hospitalier Bretagne Atlantique, Service de Néphrologie-Hémodialyse, Vannes, France
| | - Pascale Siohan
- Centre Hospitalier de Cornouaille, Service de Néphrologie-Hémodialyse, Quimper, France
| | - Eric Renaudineau
- Centre hospitalier Broussais, Service de Néphrologie-Hémodialyse, Saint-Malo, France
| | - Theophile Sawadogo
- Centre Hospitalier de Bretagne Sud, Service de Néphrologie-Hémodialyse, Lorient, France
| | - Thierry Lamy De La Chapelle
- CHU Rennes, Service d'Hématologie clinique, Rennes, France
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
- Université de Rennes 1, UMR CNRS 6290 IGDR, 35042 Rennes, France
- Université de Rennes 1, Inserm U917, Rennes, France
| | - Emmanuel Oger
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
| | - Frank Bridoux
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
| | - Cécile Vigneau
- CHU Rennes, Service de Néphrologie, Rennes, France
- CHU de Nantes, Service de Néphrologie et d'Immunologie Clinique, Nantes, France
- Centre Hospitalier Bretagne Atlantique, Service de Néphrologie-Hémodialyse, Vannes, France
- Centre Hospitalier de Cornouaille, Service de Néphrologie-Hémodialyse, Quimper, France
- Centre Hospitalier de Bretagne Sud, Service de Néphrologie-Hémodialyse, Lorient, France
- CHU Rennes, Service d'Hématologie clinique, Rennes, France
- CHU Rennes, Département de pharmacologie clinique, Rennes, France
- CHU Poitiers, Service de Néphrologie-Hémodialyse, Poitiers, France
- Université de Rennes 1, UMR CNRS 6290 IGDR, 35042 Rennes, France
- Université de Rennes 1, Inserm U917, Rennes, France
- Université de Rennes 1, IRSET, Rennes, France
- Correspondence and offprint requests to: Cécile Vigneau; E-mail:
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Abstract
Adsorption is based on the attraction between the sorbent and the solute through hydrophobic interactions, ionic or electrostatic forces, hydrogen bonding or van der Waals forces. Adsorption is the adherence of molecules by the above-mentioned forces not only to the surface of the membrane but also to its interior. Since polymethylmethacrylate membranes have a much higher inside effective exchange surface than polysulfone membranes, these membranes are able to ensure a high level of adsorption, and therefore reduce the concentration of high-molecular-weight molecules and protein-bound uremic toxins.
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Affiliation(s)
- Angelo F Perego
- Nephrology and Dialysis Unit, Monselice Hospital, Monselice, Italy.
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Santoro A, Grazia M, Mancini E. The Double Polymethylmethacrylate Filter (DELETE System) in the Removal of Light Chains in Chronic Dialysis Patients with Multiple Myeloma. Blood Purif 2013; 35 Suppl 2:5-13. [DOI: 10.1159/000350837] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Aucella F, Gesuete A, Vigilante M, Prencipe M. Adsorption Dialysis: From Physical Principles to Clinical Applications. Blood Purif 2013; 35 Suppl 2:42-7. [DOI: 10.1159/000350847] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Dialysis-related amyloidosis (DRA) is a clinical syndrome of pain, loss of function and other symptoms due to the deposition of amyloid consisting of β(2)-microglobulin (β(2)m) in the musculoskeletal system. The condition is seen in patients who suffer from chronic kidney disease and are treated with hemodialysis for a long time. Even though β(2)m easily can be manipulated to form amyloid in laboratory experiments under non-physiological conditions the precise mechanisms involved in the formation of β(2)m-amyloid in patients with DRA have been difficult to unravel. The current knowledge which is reviewed here indicates that conformational fluctuations centered around the D-strand, the DE-loop, and around the cis-configured Pro32 peptide bond are involved in β(2)m amyloidosis. Also required are highly increased concentrations of circulating β(2)m and possibly various post-translational modifications mediated by the pro-inflammatory environment in uremic blood, together with the influence of divalent metal ions (specifically Cu(2 +)), uremic toxins, and dialysis-enhanced redox-processes. It seems plausible that domain-swapped β(2)m dimers act as building blocks of β-spine cross-β -sheet fibrils consisting of otherwise globular, roughly natively folded protein. An activated complement system and cellular activation perpetuate these reactions which due to the affinity of β(2)m-amyloid for the collagen of synovial surfaces result in the DRA syndrome.
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Affiliation(s)
- Dorthe B Corlin
- Department of Clinical Biochemistry and Immunology, Division of Microbiology and Diagnostics, Statens Serum Institut, Bldg. 85/240, Artillerivej 5, 2300, Copenhagen S, Denmark,
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Santoro A, Guadagni G. Dialysis membrane: from convection to adsorption. Clin Kidney J 2010; 3:i36-i39. [PMID: 27045937 PMCID: PMC4813820 DOI: 10.1093/ndtplus/sfq035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 02/22/2010] [Indexed: 12/02/2022] Open
Abstract
Although patients undergoing dialysis have a complex illness, there are compelling reasons to believe that the inadequate removal of organic waste is an important contributing factor to the illness itself. This paper focuses on the transport phenomena that occur within a dialyser. An attempt is made to clarify how transport phenomena are related to the performance of a dialysis session and how they depend on the membrane characteristics. Our study offers some discussion points on the complex issue of defining what the best parameters could be in comparing the efficiency of different membranes. The new high-flux dialysers have improved larger-molecule clearance and biocompatibility. Membrane performance is a very hard process to evaluate, and different membranes can only be compared by establishing adequate points of comparison. At the same time, the points of comparison themselves may change depending on the type of co-morbidities of the specific patient who is considered for membrane selection. This editorial (together with all the papers presented in this issue) seeks to focus on the membrane's own merits in improving the dialysis therapy.
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Affiliation(s)
- Antonio Santoro
- Division of Nephrology, Dialysis and Hypertension, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Via Palagio Palagi 9, 40138, Bologna , Italy
| | - Gualtiero Guadagni
- Division of Nephrology, Dialysis and Hypertension, Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Via Palagio Palagi 9, 40138, Bologna , Italy
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Lee KS, van Holsbeeck MT, Abbud A. Atypical rapid progression of osteoarticular amyloidosis involving the hip in a patient on hemodialysis using polyacrylonitrile membranes. Skeletal Radiol 2010; 39:79-83. [PMID: 19707759 DOI: 10.1007/s00256-009-0779-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 08/03/2009] [Accepted: 08/06/2009] [Indexed: 02/02/2023]
Abstract
Amyloidosis related to dialysis is a well-known complication affecting many organ systems, in particular the musculoskeletal system. In 1985 Shirahama et al. (Biochem Biophys Res Commun 53:705-709, 1985) identified beta-2 microglobulin (MG) as the offending constituent by using protein purification techniques. Amyloidosis has been increasing in prevalence because of longer life spans and increased chronic medical conditions such as end-stage renal disease. When dialysis-related amyloidosis involves the musculoskeletal system, it affects the shoulder girdle, the so called shoulder pad sign, the wrist, hip, knee, and spine (Resnick, Diagnosis of bone and joint disorders, 4th edn., pp. 2054-2058 and 2176-2183, 2002). Other osteoarticular manifestations of amyloidosis include osteoporosis, lytic lesions, and pathologic fractures. It has been well documented that the prevalence of amyloid is dependent on duration of dialysis-over 90% in patients on dialysis for over 7 years (Jadoul, Nephrol Dial Transplant 13:61-64, 1998). However, a recent changeover to high-flux membranes used in hemofiltration has been reported to delay its onset (Campistol et al., Contrib Nephrol 125:76-85, 1999). We report on the radiographic, nuclear medicine, and computed tomography (CT) findings of osteoarticular amyloidosis involving the hip, and sequence its atypical rapid onset. The imaging, histopathological findings, and differential diagnosis are discussed.
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Affiliation(s)
- Kenneth S Lee
- Department of Radiology, University of Wisconsin Hospital and Clinics, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue CSC E3/311, Madison, WI 53792-3252, USA.
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Moachon N, Boullange C, Fraud S, Vial E, Thomas M, Quash G. Influence of the charge of low molecular weight proteins on their efficacy of filtration and/or adsorption on dialysis membranes with different intrinsic properties. Biomaterials 2002; 23:651-8. [PMID: 11771685 DOI: 10.1016/s0142-9612(01)00151-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hemodialysis membranes eliminate by filtration low-molecular-weight toxic metabolites (urea and creatinine) with minimum interactions between blood components and the membrane itself. However, the ability of a membrane to adsorb specific proteins could be beneficial if the accumulation of these same proteins is implicated in the genesis of a pathological condition. Beta-amyloidosis which accompanies the elevation of beta2-microglobulin (11.8 kDa) in the plasma of dialysed patients is one such condition (Biochem. Biophys. Res. Commun. 129 (3) (1985) 701-706: Lancet 1 (1986) 1240-1311). To determine whether increases in plasma beta2-microglobulin levels were due to differences in filtration efficacy of the membrane used and/or to certain characteristics of this protein, e.g. its charge (pI 5.7) the adsorption and filtration of [3H] beta2-microglobulin and [3H] lysozyme of similar MW 14.5 kDa, but pI: 10.8 were compared on different membranes. It was found that, neither [3H] beta2-microglobulin nor [3H] lysozyme are removed by cuprophan, whereas over 75% of beta2-microglobulin is removed by filtration on polyacrylonitrile, polyacrylonitrile-polyethyleneimine, polysulfone and >95% by adsorption to polymethylmethacrylate-BK. For lysozyme, removal by adsorption is >95% on polyacrylonitrile and polyacrylonitrile-polyethyleneimine, 72% on polymethylmethacrylate-BK and by filtration is 95% on polysulfone. Hemodialysis membranes must therefore not simply be considered as filters of low-molecular-weight metabolites but should be equally assessed for their capacity to eliminate potentially deleterious low-molecular-weight plasma proteins.
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Affiliation(s)
- N Moachon
- Laboratoire d'Immunochimie, INSERM 4329, Faculté de Médecine Lyon-Sud, Université Claude Bernard, Lyon I, Oullins, France
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Abstract
Early after the identification of beta(2)-microglobulin amyloidosis (A beta(2)M) as the cause of carpal tunnel syndrome, it was thought that hemodialysis was a major cause in the development of the disease. It was subsequently shown that hemodialysis was not necessary for the development of dialysis-related amyloidosis; however, it was believed that the different dialysis membranes did modulate the progression of the disease. Current data demonstrate that hemodialysis fails to prevent or reverse the disease, but there is substantial evidence that high-flux, high-efficiency dialyzers slow its progression. Many factors related to hemodialysis have been evaluated in relation to A beta(2)M, including the effect of the bioincompatibility of the membrane, the capacity of the different membranes to remove beta(2)M, and the effect of reuse on beta(2)M levels. Moreover, there have been intensive efforts to evaluate, explore, and improve the different mechanisms in beta(2)M removal, with adsorption as a promising prospect. With the available evidence, it seems that the removal of beta(2)M by the membrane plays the most important role in modulating the disease outcome and rate of progression, although a large, long-term, multicentered and randomized study is still lacking to prove this relationship. However, it is possible that with the continuing advances in optimizing the beta(2)M removal efficiency of the different membranes, the frequency and severity of the disease can be substantially decreased.
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Affiliation(s)
- M I Jaradat
- Indiana University School of Medicine and Richard Roudebush VA Medical Center, Indianapolis, Indiana 46202, USA
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