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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 139-145

Epidemiological study of body fat percentage, lean body mass, and total body water for Asian patients with chronic kidney disease


1 Department of Nephrology, Pyongyang Medical College, Kim Il Sung University, Pyongyang, Democratic People's Republic of Korea
2 Department of Cutting-Edge Production Institute Nutrition of Child, Medical Academy of Science, Pyongyang, Democratic People's Republic of Korea

Date of Submission10-Apr-2019
Date of Decision25-Sep-2019
Date of Acceptance03-Jun-2020
Date of Web Publication8-Oct-2020

Correspondence Address:
Song-Hui Kim
Department of Nephrology, Pyongyang Medical College, Kim Il Sung University, Ryonhwa-Dong, Central District, Pyongyang
Democratic People's Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_33_19

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  Abstract 


Background: Malnutrition can have reversible effects on patients with chronic kidney disease (CKD). Patients with CKD are exposed to a wasting syndrome, because of disorders of nutrient absorption, excretion, and other factors. Aim: The aim is to identify changes in body fat percent (BFP), lean body mass (LBM), and total body water (TBW) percentage in patients with CKD using bioelectrical impedance analysis (BIA). Setting and Design: This study was conducted in 438 CKD patients (212 males and 226 females) attending a Nephrology Clinic in a Tertiary Level University hospital from 2008 to 2014, who were followed up for 6 months. Materials and Methods: The anthropometric and BIA data of all patients, who consented to participate, was collected and analyzed for LBM, BFP, and percentage of TBW. Results: Correlation coefficient of body mass index (BMI) and glomerular filtration rate is 0.20 and 0.227 in men and women in 0 week (baseline), respectively. In 24 weeks (endpoint), that is, 0.526 and 0688. In male patients, the average value of BFP was decreased 0.9%–1.4%, the average LBM was decreased 0.5–1.3 (kg/m, height), and then the average percentage of TBW was increased 0.3%–0.9% after G3 stage. In one side, in female patients, BFP was increased 0.3%–2.9%, the LBM was decreased 0.4–0.7 (kg/m, height), and then average percentage of TBW was increased 0.2%–0.8% after G3 stage. Collectively, BMI, LBM, and BFP were decreased according to CKD stage, in contrast with this, TBW percentage was increased. Discussion: These results suggest that protein-energy malnutrition is the main factor related to malnutrition in patients with CKD. The LBM and BFP were decreased, and percentage of TBW was increased in CKD.

Keywords: Bioimpedance analysis, body fat percentage, chronic kidney disease, lean body mass, total body water


How to cite this article:
Kim SH, Bang YI, Ri Y, Choe GH. Epidemiological study of body fat percentage, lean body mass, and total body water for Asian patients with chronic kidney disease. CHRISMED J Health Res 2020;7:139-45

How to cite this URL:
Kim SH, Bang YI, Ri Y, Choe GH. Epidemiological study of body fat percentage, lean body mass, and total body water for Asian patients with chronic kidney disease. CHRISMED J Health Res [serial online] 2020 [cited 2020 Oct 29];7:139-45. Available from: https://www.cjhr.org/text.asp?2020/7/2/139/297576




  Introduction Top


The three primary functions of the kidney are excretory, endocrine and metabolic, each of which may be impaired to a variable degree in chronic kidney disease (CKD). With progressive injury, necrosis and scarring in the kidney, the nutritional status of CKD patients gradually deteriorates.

CKD has been classified into five stages using glomerular filtration (GFR), i.e., CKD Stage 1: GFR ≥90 mL/min/1.73 m2, Stage 2: 60–89 mL/min/1.73 m2, Stage 3: 30–59 mL/min/1.73 m2, Stage 4: 15–29 mL/min/1.73 m2, and Stage 5: Under 15 mL/min/1.73 m2.[1],[2],[3] Kidney regulates concentrations of water, minerals, vitamins, other nutrients, and their metabolites. The patients with CKD, who have sustained a substantial loss of GFR often continue to lose kidney function inexorably until they develop end-stage renal disease.

Malnutrition can have important but usually reversible effects on kidney function.[4],[5] Chazot et al.[6] reported that the body weight, body mass index (BMI), arm-muscle circumference (AMC), arm-muscle area (AMA), and triceps skinfold thickness (TSF) in Group A (average hemodialysis treatment period is 304 months) were lower than in Group B (HD treatment period is 51 months).

Lawson et al.[7] assessed nutritional status by subjective global assessment (SGA) criteria in patients' with chronic renal insufficiency. At baseline assessment, 28% of patients had evidence of malnutrition by SGA criteria. The malnourished group of patients had a significantly lower creatinine clearance and mid upper-arm circumference.

The majority of CKD patients had malnourishment.[8],[9],[10] Valenzuela et al.[11] assessed the CKD patients' status using anthropometric indices such as BMI, AMA, and TSF, biochemical tests, protein nitrogen appearance rate, and average food intake. They observed that 38% of females and 27% of males had normal range of BMI and AMA, and the others had decreased range, and the TSF of 39% of females and 20% of males was lower, falling in the 5th percentile. Total energy and protein intake of 74% of them were lower than healthy individual's intakes. The BMI of maintenance hemodialysis (MHD) patients, who had no diabetes, was significantly lower and had more underweight and malnutrition than MHD patients, who had diabetes. This indicated that there is a positive relationship between malnutrition and mortality or morbidity in CKD patients.[12]

Pupim and his colleagues[13] was reported a cohort study result that the nutritional status of chronic hemodialysis (CHD) patients can predicts their mortality independently. The reasons for malnutrition in CKD are under-excretion of uremic substances, disorder of taste, anorexia, gastric disorder, metabolic factors like acidosis, as well as sepsis and its complications relate to malnutrition.


  Materials and Methods Top


Purpose

The purpose is to identify the nutritional aspects of body fat percentage (BFP), lean body mass (LBM), and percentage of total body water (TBW) in patients with CKD over a 24 weeks' period.

A total of 438 patients with CKD attending the Nephrology Department of Pyongyang Medical College, Kim Il Sung University from 2008 to 2014 were enrolled if they the inclusion criteria and gave consent to participate.

Methodology

The CKD staging was based on glomerular filter rate (GFR). The CKD stage was based on estimated GFR (eGFR) using MDRD formula,[6] anthropometric indices included height, current weight, ideal weight, and bioelectrical impedance analysis (BIA) was used to measure LBM, BFP, and percentage of TBW.[14]

We estimated the above parameters in the patients at the start of the study and at the end point at 6 months. The patients' urine was collected for 24 h to estimate; the urine creatinine using alkaline picric acid method.

The body weight and height was measured using weight scale and height ruler. BMI (kg/m2) was calculated using BMI formula (body weight [kg] divided square of height [m2]). LBM, BFP, and percentage of TBW was measured using BIA measuring instrument.

Statistical analysis

All data are expressed as mean and standard deviation (or standard error). The statistical analyses were carried out by SPSS (IBM Corp., New York. USA). Statistical significance was determined by Turkey multiple means comparison test (P < 0.05).


  Results Top


Number and percentage of patients based on CKD stage, gender, and age.

[Table 1] shows number and percentage of patients based on gender. The number of female patients slightly outnumbered males.
Table 1: Gender: Number and percentage based on chronic kidney disease stage

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[Table 2] shows number and percentage of patients based on age groups. The maximum number of patients were in the over 50 to under 40 years of age. In other words, the number of patients who are over middle aged was bigger than under middle aged.
Table 2: Age: Number and percentage based on chronic kidney disease stage

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Change of BMI and body weight in the patients according to CKD stage.

[Table 3] shows BMI (kg/m2) of patients based on 0 and 24 weeks and shows delta value of BMI between 0 and 24 weeks. Decreased average value of BMI was 0.1–0.4 for 24 weeks. Especially, the patients' BMI, who was in G4 and G5 stage, was more decreased than G1 and G2.
Table 3: Average body mass index according to chronic kidney disease stage

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[Table 4] shows changing appearance for patients' body weight in decrease and increase group. 330 patients of all (male is 145; female is 185) were in small decrease group and 65 patients were in extremely decrease group. In addition, 43 patients were in small increase group, but there is not any one person, who was in extremely increase group. In other way, 90.1% of all had decreasing weight, and 9.9% had increasing weight.
Table 4: Change of body weight in 0 and 24 weeks by followed chronic kidney disease stage

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[Figure 1] shows average change in body weight (Delta value) according to CKD stage over 6 months. Each value was estimated as delta (weight of 24 weeks minus weight of 0 week) divided by observed days. In G1, the average loss of CKD stage was 4–8 g/day; in G2, it was 6–11 g; in G3a, it was 11–21 g; in G3b, it was 11–22 g; in G4, it was 18–22 g; in G5, it was about 23 g. As the CKD progressed from one stage to a more severe stage, weight loss per day gradually increased.
Figure 1: Average delta value of body weight according to chronic kidney disease stage. Average delta value of body weight according to chronic kidney disease stage. Loss weight was calculated that changed mass for 24 weeks per an individual divided 168 days (about 6 months). Significant loss weight represented after G3b, especially, in G5 stage of male and female, average loss weight per a day was approximately 20 g. Cornflower blue dot line shows female's data, chocolate dot line shows male's data

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[Figure 2] shows BMI distribution and quire tile curve from 0 and 24 weeks in the male and female patients. Correlation coefficient between BMI and eGFR in 0 week is 0.20 and 0.22 in male and female, respectively; the same value in 24 weeks is 0.688 and 0.526 in male and female, respectively, in significance level of P < 0.05.
Figure 2: Body mass index distribution and quire tile curve in 0 and 24 weeks. Body mass index distribution and quartile curve in 0 and 24 weeks according to glomerular filtration. (a and b) shows quartile curve of body mass index in female and male in 0 and 24 weeks, respectively. Resulting of observation for subjects, the GFR lower, the more body mass index was decreased

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The patients' average body weight, G3 to G5, was gradually lost during average 24 weeks' period. That is, it could be divided into two groups, i.e., Those with body weight decrease and the others with body weight increase. There were 395 patients all (90.1%) in weight decrease group, and others were in weight increase group. In addition, 145 patients (68.3%) were in the small decrease group; 39 male patients (18.3%) were in extremely decrease group; 185 female patients (82.3%) were in small decrease group; 26 female patients (11.5%) were in extremely decrease group. Especially, it showed up enormous body weight lost after G3b [Table 4].

Change of BFP, LBM and percentage of TBW in the patients according to CKD stage.

[Table 5] shows average BFP in 0 and 24 weeks, respectively. In male patients, average BFP was decreased 0.1%–1.4% (%) during survival period. However, in female patients, it was increased 0.3%–2.9% during survival period. In addition, BFP had decreasing tendency according to CKD stage in male patients; in reversely, it had increasing tendency according to it in female patients. Collectively, the male patients' average BFP, whose were included in G3 to G5, was significantly under than normal; the female patients, whose were in it, had similar value than normal.
Table 5: Average body fat percent in 0 and 24 weeks according to chronic kidney disease stage

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[Table 6] shows average LBM (kg/m, height) in 0 and 24 weeks, respectively. In male patients, average LBM was decreased 0.5–0.7 (kg/m, height); in female patients, that value was decreased 0.2–1.1 (kg/m, height) during this period. In other way, the LBM was significantly lower than G1 or G2 over G4 stage. So that, the patient's average LBM, whose included in G3 to G5, was tendency to under than normal.
Table 6: Average lean body mass in 0 and 24 weeks according to chronic kidney disease stage

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[Table 7] shows average percent of TBW (%) in 0 and 24 weeks, respectively. In male patients, the average TBW percentage was increased 0.3%–0.7%; in female patients, it was increased 0.2%–0.7% during survival period. The patients' average TBW percentage showed tendency to an increase.
Table 7: Average percent of total body water in 0 and 24 weeks according to chronic kidney disease stage

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  Discussion Top


Kidney is important organ for human's life. By the way, if kidney is disorder by CKD, it cannot excrete metabolisms such ads ammonia and urea, and cannot reabsorb nutrients such as protein, amino acid, vitamins.[3],[15] So that, CKD patient's nutrition status is gradually and continuously lower than one's health. Until now, many research workers reviewed about CKD patient's nutrition, but we did not found epidemiologic data, that was about LBM, BFP and percentage of TBW.

Hence, we studied to identify changes in BFP, LBM and TBW percent in patients with CKD using BIA technology.[16] In other way, we studied to find how the BMI, body weight, LBM, BFP, and percentage of TBW of CKD patients changes according to CKD stage over 6 months in this epidemiologic survey.

The data presented in the present study is based on the observations on 438 patients with almost an equal number of males and females. The number of male patients is 212, female is 226. So that, the females were more than males, the ration of male and female is 0.93–1 [Table 1]. The number of patients according to age group is that under twenties is 2 persons; the twenties is 66 persons; the thirties is 84 persons; the forties is 83 persons; fifties is 91 persons; and over sixties is 112 persons [Table 2].

BMI, LBM, BFP, and percentage of TBW is good anthropometric parameters for measuring human's nutrition status. Hence, we surveyed the patient's nutrition status using these parameters.

First, we researched BMI and weight how these parameters were changed. Average BMI (kg/m2) was 18.5–21.0 and 19.9–22.7 in male and female in 0 week, respectively. However, after 6 months, it was 18.2–20.8 and 19.6–22.4 in male and female, respectively. This is showing that the patient's BMI was decreased about 0.1–0.4 for 6 months [Table 3]. And then, the weight could be divided into two group, one was decrease group, and the other was increase group. The patient's number in decrease group was 394 (90.1%; 395/438), and it in increase group was 43 (9.9%; 43/438). This is showing that the CKD patient's weight is gradually decreasing in CKD patients. But the patients, who was in increase group, has tendency of small increase, and eleven persons of them has edema [Table 4]. Many researcher was reviewed about change of CKD patients. Pupim et al.[17] were studied about relationship of hemodialysis and post dialysis weight in chronic hemodialysis (CHD) patients. The CHD patient's weight was lower than normal, and the weight may be decreased as long as he has been hemodialysis.

Second, we measured the BFP, LBM and percentage of TBW in 0 and 24 weeks by BIA, respectively. Human's fat is important a storing place of energy, if fat mass is lowest than normal, he has malnutrition such as marasmus. LBM shows body's muscle mass, if it is lower than normal, he has malnourished like kwashiorkor. If fat and muscle mass are lower than health, he has protein-energy malnutrition.[10] mentioned that malnutrition in CHD patients, which was assessed by protein catabolic rate, SGA, TSF, mid-arm muscle circumference (MMC) and BMI, appear in almost HD patients.

There are main three ways for measurement of body compositions such as fat, muscle, and water; first is skinfold thickness measurement, second is densitometry, and third is BIA method. Of all these measurement, we selected BIA method, measure the BFP, LBM, and percentage of TBW in 0 and 24 weeks.

The average BFP (%) of the male patients was 11.7–14.2 in 0 week, but it was 10.8–14.1 in 24 weeks according to CKD stage. Moreover, it of the female was 21.4–24.6 and 22.3–27.5 in 0 and 24 weeks, respectively. Eventually, BFP was decreased 0.1%–1.4% over 24 weeks in male. Especially, after G3 stage, it was more decreased (0.9%–1.4%). However, it was increased in female patients; the value was 1.1%–2.9% [Table 5]. The standard of BFP is for men: Under 5% is thin; 8%–15% is normal; 16%–20% is overweight; over 20 is obesity, and it is for women: Under 13% is thin; 13%–23% is normal; 24%–27% is overweight; over 27 is obesity.[18] When our result about BFP compares with this standard, the percentage value of all patients was entered into normal range, but had tendency of gradually decreasing in male patients and gradually increasing in female patients.

In CKD patient, because of disorder of protein metabolism, body's muscle mass is lower than normal.[3] Hence, we measured patient's LBM to find how the muscle mass changes in survey period. On our research result, the average of LBM (kg/m, height) was 29.1–30.8 and 28.4–30.1 in 0 and 24 weeks in male patients, respectively. And then, the average of it was 23.3–26.8 and 22.6–26.7 in 0 and 24 weeks in female patients, respectively [Table 6]. Eventually, the average value of it was decreased 0.5–1.3 and 0.3–1.3 in male and female, respectively. Especially, the value was more decreased over G3 stage. Lawson et al.[7] were mentioned that the patient's mid-arm circumference, who has chronic renal insufficiency, lower than normal. And on end point of Cohort, the survival of malnutrition patient was higher than patient, who has no malnutrition. Valenzuela et al.[11] were reported that 39% of men and 2% of women presented mid AMC (MAMC) bellow the 5th percentile, and showed that lose body fat and muscle stores.

Kidney excretes several waste materials with water. By the way, if kidney has chronic insufficiency, the materials and water cannot be excreted. Hence, the edema is happened on CKD patient. The average percent of TBW (%) was 62.5–64.9 and 62.8–65.2 in men in 0 and 24 weeks, respectively. And then, the average percentage was 53.7–57.0 and 53.0–56.8 in women in this period, respectively. Over 24 weeks, average TBW percentage was increased 0.3%–0.6% and 0.2%–0.8% in men and women, respectively [Table 7]. By the by, the patients in G5 stage of women was decreased 0.8%. Hence, we clinical observed for them, why the percentage of TBW was decreased. At result, some of them had polyuria for long term. Sarkar et al.[19] assessed body composition in long-term hemodialysis patients using dual-energy X-ray absorptiometry and bioelectrical impedance technology. They got research data that muscle, fat and fat-free mass of these patients was lower than health. Dumler et al.[20] was mentioned that there is no difference between baseline and 9 months in TBW (44.4 ± 11.4 vs. 44.6 ± 10.8 L, respectively).


  Conclusion Top


By this study, we found new research data that LBM and BFP had tendency of decrease, and percentage of TBW had tendency of increase. And then, the value of LBM was smaller as much as percentage of TBW was bigger.

Moreover, in this epidemiological survey, we measured LBM, BFP, and percentage of TBW in 438 patients (male 212, female 226) with CKD at 0 week (baseline) and 24 weeks using BIA technology. As a result, the weight in almost of them was gradually decreased.

The average value of BFP and LBM had decreasing tendency and the average percentage of TBW had increasing tendency.

And then, the relationship correlation between BMI and GFR was 0.20 and 0.688 in 0 and 24 weeks in male, respectively (P < 0.01). And, it was 0.227 and 0.526 in female, respectively (P < 0.01).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Coresh J, Stevens LA. Kidney function estimating equations: Where do we stand?Curr Opin Nephrol Hypertens 2006;15:276-84.  Back to cited text no. 2
    
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Mak RH, Cheung W. Energy homeostasis and cachexia in chronic kidney disease. Pediatr Nephrol 2006;21:1807-14.  Back to cited text no. 5
    
6.
Chazot C, Laurent G, Charra B, Blanc C, VoVan C, Jean G, et al. Malnutrition in long-term haemodialysis survivors. Nephrol Dial Transplant 2001;16:61-9.  Back to cited text no. 6
    
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Lawson JA, Lazarus R, Kelly JJ. Prevalence and prognostic significance of malnutrition in chronic renal insufficiency. J Ren Nutr 2001;11:16-22.  Back to cited text no. 7
    
8.
Goldstein-Fuchs DJ. Assessment of nutritional status in renal disease. In: Mitch WE, Klahr S, editors. Nutrition and the Kidney. 4th ed.. Philadelphia: Lippincott-Raven Press; 2002. p. 42.  Back to cited text no. 8
    
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Raffaitin C, Lasseur C, Chauveau P, Barthe N, Gin H, Combe C, et al. Nutritional status in patients with diabetes and chronic kidney disease: A prospective study. Am J Clin Nutr 2007;85:96-101.  Back to cited text no. 9
    
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Ikizler TA, Greene JH, Wingard RL, Parker RA, Hakim RM. Spontaneous dietary protein intake during progression of chronic renal failure. J AM Soc Nephrol. 1995;6:1386.  Back to cited text no. 10
    
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Valenzuela RG, Giffoni AG, Cuppari L, Canziani ME. Nutritional condition in chronic renal failure patients treated by hemodialysis in Amazonas. Rev-Assoc-Med-Bras. 2003;49:72-8.  Back to cited text no. 11
    
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Lorenzo V, Martin M, Rufino M, Sanchez E, Jimenez A, Hernandez D, Torres A. High prevalence of overweight in a stable Spanish hemodialysis population: a cross sectional study. Journal of Renal Nutrition. 2003;13:52-9.  Back to cited text no. 12
    
13.
Pupim LB. Caglar K, Hakim RM, Shyr Y, Ikizler TA. Uremic malnutrition is a predictor of death independent of inflammatory status. Kidney Int: 2004;66:2054.  Back to cited text no. 13
    
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Rosalind S. Gibson. Principles of nutritional assessment. Oxford University Press. 1990.  Back to cited text no. 14
    
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Kopple JD. Nutrition, Diet, and the Kidney. In Maurice ES, Moshe Shike, A. Catharine Ross, Benjamin Caballero, Robert J. Cousins. Modern nutrition in health and disease. 10th ed. Lippincott Williams & Wilkins. 2005. p. 1475-511.  Back to cited text no. 15
    
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Macdonald JH, Marcora SM, Jibani M, Roberts G, Kumwenda MJ, Glover R, et al. Bioelectrical impedance can be used to predict muscle mass and hence improve estimation of glomerular filtration rate in non-diabetic patients with chronic kidney disease. Nephrol-Dial-Transplant 2006:21:3481-7.  Back to cited text no. 16
    
17.
Pupim LB. Caglar K, Hakim RM, Shyr Y, Ikizler TA. Uremic malnutrition is a predictor of death independent of inflammatory status. Kidney Int: 2004;66:2054.  Back to cited text no. 17
    
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Lee RD. Nutritional Assessment 3th ed, Mc Graw-Hill. 2003. p. 73-355.  Back to cited text no. 18
    
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Sarkar SR, Kuhlmann MK, Khilnani R, Zhu F, Heymsfield SB, Kaysen GA, et al. Assessment of body composition in long-term hemodialysis patients: rationale and methodology. J-Ren-Nutr. 2005;15:152-8.  Back to cited text no. 19
    
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Dumler F, Kilates C. Prospective nutritional surveillance using bioelectrical impedance in chronic kidney disease patients. J-Ren-Nutr. 2005; 15:148-51.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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