4020bfd52e52edeeb983f35806040fab  322727.pdf
ca85192307f284820ac421a5d968e4ad47d2c055  322727.pdf
fde0f78d191b3aa49a64fc6ffc9b5cb5892b606cb896fca4e1f0a9ec511f187c  322727.pdf

Title:           Pediatric Liver and Kidney Transplant Recipients Demonstrate Greater Serological Response to SARS-CoV-2 Vaccination Than Adults
Subject:         DOI: 10.1097/TXD.0000000000001787
Transplantation Direct, Volume. 11, Issue. 5, 29 April 2025
Background. Adult solid organ transplant recipients (SOTRs) have decreased responsiveness to severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) vaccination and higher incidence of infection, but there are few data on the serological response in pediatric SOTR. The aim of this study was to determine serological response to SARS-CoV-2 vaccination in pediatric liver (LT) and kidney transplant (KT) recipients and compare it with adult SOTR. Methods. A European, prospective, multicenter study was performed. Samples were taken at 7 and 32 wk following COVID-19 vaccination and serological endpoints were measured by ELISA. Results. A total of 42 pediatric (16 post-LT and 26 post-KT) and 117 adult (all post-LT) were included. All pediatric participants and 94% adult participants received mRNA vaccines. Paediatric SOTR patients had significantly higher anti-Spike IgG levels than adult participants at week 7 (114 220.7 [59 285.92–220 058.55] versus 8756.7 [5643.69–13 586.71], P < 0.0001) and week 32 (46 113.2 [10 992.91–193 436.14] versus 8207.0 [3561.20–18 913.43], P = 0.0032). No significant difference in week 7 anti-Spike IgG response was found between pediatric LT and KT (129 434.4 [51 888.64–322 869.69] versus 105 304.5 [39 910.20–277 849.50], P = 0.9854). No differences were seen between children and adults in the rate of decline of anti-Spike IgG between weeks 7 and 32 (P = 0.8000). Male sex and hemolytic-uremic syndrome or postischemic kidney disease were associated with lower anti-Spike IgG levels at week 7 in pediatric SOTR. Conclusions. Paediatric SOTR demonstrate greater SARS-CoV-2 vaccine responses than comparable adult SOTR patients. These data support efficacy and safety of SARS-CoV-2 vaccination in child SOTR and may alleviate vaccine hesitancy in this patient group. 
Author:          Tobias Laue 
Creator:         Adobe InDesign 15.1 (Windows)
Producer:        Adobe PDF Library 15.0
CreationDate:    Tue Apr 29 09:30:15 2025 CEST
ModDate:         Tue Apr 29 09:30:17 2025 CEST
Custom Metadata: no
Metadata Stream: yes
Tagged:          yes
UserProperties:  no
Suspects:        no
Form:            none
JavaScript:      yes
Pages:           9
Encrypted:       no
Page size:       558 x 774 pts
Page rot:        0
File size:       1097215 bytes
Optimized:       no
PDF version:     1.4


name                                 type              encoding         emb sub uni object ID
------------------------------------ ----------------- ---------------- --- --- --- ---------
HelveticaNeueLTStd-Bd                Type 1C           WinAnsi          yes no  yes    269  0
HelveticaNeueLTStd-HvEx              Type 1C           WinAnsi          yes no  yes    270  0
HelveticaNeueLTStd-Roman             Type 1C           WinAnsi          yes no  yes    271  0
ZapfDingbatsStd                      Type 1C           Custom           yes no  yes    272  0
HelveticaNeueLTStd-Lt                Type 1C           Custom           yes no  yes    273  0
HelveticaNeueLTStd-Md                Type 1C           WinAnsi          yes no  yes    274  0
HelveticaNeueLTStd-MdEx              Type 1C           WinAnsi          yes no  yes    275  0
HelveticaNeueLTStd-Hv                Type 1C           WinAnsi          yes no  yes    276  0
HelveticaNeueLTStd-BdEx              Type 1C           WinAnsi          yes no  yes    277  0
HelveticaNeueLTStd-LtIt              Type 1C           Custom           yes no  yes    278  0
HelveticaNeueLTStd-Ex                Type 1C           WinAnsi          yes no  yes    312  0
SabonLTStd-Roman                     Type 1C           Custom           yes no  yes    313  0
SabonLTStd-Bold                      Type 1C           WinAnsi          yes no  yes    314  0
SabonLTStd-Italic                    Type 1C           WinAnsi          yes no  yes    319  0
HelveticaNeueLTStd-BdCn              Type 1C           WinAnsi          yes no  yes    322  0
HelveticaNeueLTStd-LtCn              Type 1C           Custom           yes no  yes    323  0
HelveticaNeueLTStd-LtCnO             Type 1C           WinAnsi          yes no  yes    324  0
HelveticaNeueLTStd-BdCnO             Type 1C           WinAnsi          yes no  yes    342  0


Jhove (Rel. 1.28.0, 2023-05-18)
 Date: 2025-12-12 04:55:22 CET
 RepresentationInformation: 322727.pdf
  ReportingModule: PDF-hul, Rel. 1.12.4 (2023-03-16)
  LastModified: 2025-12-11 11:52:11 CET
  Size: 1097215
  Format: PDF
  Version: 1.4
  Status: Well-Formed and valid
  SignatureMatches:
   PDF-hul
  MIMEtype: application/pdf
  Profile: Tagged PDF
  PDFMetadata: 
   Objects: 2412
   FreeObjects: 1
   IncrementalUpdates: 0
   DocumentCatalog: 
    ViewerPreferences: 
     HideToolbar: false
     HideMenubar: false
     HideWindowUI: false
     FitWindow: false
     CenterWindow: false
     DisplayDocTitle: false
     NonFullScreenPageMode: UseNone
     Direction: L2R
     ViewArea: CropBox
     ViewClip: CropBox
     PrintArea: CropBox
     PageClip: CropBox
    PageLayout: SinglePage
    PageMode: UseNone
    Language: en-US
    Outlines: 
     Item: 
      Title: Pediatric Liver and Kidney Transplant Recipients Demonstrate Greater Serological Response to SARS-CoV-2 Vaccination Than Adults
      Children: 
       Item: 
        Title: MATERIALS AND METHODS
        Children: 
         Item: 
          Title: Study Design and Participants
         Item: 
          Title: Data Collection and Biological Sampling
         Item: 
          Title: Laboratory Methods
          Children: 
           Item: 
            Title: Anti-Spike and Receptor-binding Domain IgG Immunoassays
         Item: 
          Title: Statistical Analyses
          Children: 
           Item: 
            Title: Descriptive Analyses and Humoral Responses to COVID-19 Vaccination
           Item: 
            Title: Factors Associated With COVID-19 Vaccine Response
           Item: 
            Title: Software and Data Quality Assurance
           Item: 
            Title: Research Reproducibility Approach
         Item: 
          Title: Ethics
       Item: 
        Title: RESULTS
        Children: 
         Item: 
          Title: Participants
         Item: 
          Title: Humoral Immune Responses to COVID-19 Vaccination
         Item: 
          Title: Factors Associated With Antibody Levels in Pediatric Patients
         Item: 
          Title: Rate of Decline of Serological Response
       Item: 
        Title: DISCUSSION
       Item: 
        Title: REFERENCES
   Info: 
    Title: Pediatric Liver and Kidney Transplant Recipients Demonstrate Greater Serological Response to SARS-CoV-2 Vaccination Than Adults
    Author: Tobias Laue 
    Subject: DOI: 10.1097/TXD.0000000000001787
Transplantation Direct, Volume. 11, Issue. 5, 29 April 2025
Background. Adult solid organ transplant recipients (SOTRs) have decreased responsiveness to severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) vaccination and higher incidence of infection, but there are few data on the serological response in pediatric SOTR. The aim of this study was to determine serological response to SARS-CoV-2 vaccination in pediatric liver (LT) and kidney transplant (KT) recipients and compare it with adult SOTR. Methods. A European, prospective, multicenter study was performed. Samples were taken at 7 and 32 wk following COVID-19 vaccination and serological endpoints were measured by ELISA. Results. A total of 42 pediatric (16 post-LT and 26 post-KT) and 117 adult (all post-LT) were included. All pediatric participants and 94% adult participants received mRNA vaccines. Paediatric SOTR patients had significantly higher anti-Spike IgG levels than adult participants at week 7 (114 220.7 [59 285.92–220 058.55] versus 8756.7 [5643.69–13 586.71], P < 0.0001) and week 32 (46 113.2 [10 992.91–193 436.14] versus 8207.0 [3561.20–18 913.43], P = 0.0032). No significant difference in week 7 anti-Spike IgG response was found between pediatric LT and KT (129 434.4 [51 888.64–322 869.69] versus 105 304.5 [39 910.20–277 849.50], P = 0.9854). No differences were seen between children and adults in the rate of decline of anti-Spike IgG between weeks 7 and 32 (P = 0.8000). Male sex and hemolytic-uremic syndrome or postischemic kidney disease were associated with lower anti-Spike IgG levels at week 7 in pediatric SOTR. Conclusions. Paediatric SOTR demonstrate greater SARS-CoV-2 vaccine responses than comparable adult SOTR patients. These data support efficacy and safety of SARS-CoV-2 vaccination in child SOTR and may alleviate vaccine hesitancy in this patient group. 
    Creator: Adobe InDesign 15.1 (Windows)
    Producer: Adobe PDF Library 15.0
    CreationDate: Tue Apr 29 10:00:15 CEST 2025
    ModDate: Tue Apr 29 10:00:17 CEST 2025
   ID: 0x749aa9c14a46e94fa365d9f11641c1e2, 0x5ebfce6052c36c41ab9ad9b50eb36cdb
   Filters: 
    FilterPipeline: FlateDecode
   Images: 
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 1000
      ImageHeight: 196
      ColorSpace: black is zero
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
     Intent: RelativeColorimetric
     Name: X
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 1301
      ImageHeight: 849
      ColorSpace: black is zero
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
     Intent: RelativeColorimetric
     Name: X
    Image: 
     NisoImageMetadata: 
      FormatName: image/png
      ImageWidth: 1300
      ImageHeight: 790
      ColorSpace: black is zero
      BitsPerSample: 8
      BitsPerSampleUnit: integer
     Filter: FlateDecode
     Intent: RelativeColorimetric
     Name: X
   Fonts: 
    Type1: 
     Font: 
      BaseFont: HelveticaNeueLTStd-BdCn
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-BdCn
       Flags: Nonsymbolic
       FontBBox: -164, -224, 1066, 961
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-LtCn
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-LtCn
       Flags: Nonsymbolic
       FontBBox: -167, -204, 1000, 927
       FontFile3: true
      EncodingDictionary: 
       BaseEncoding: WinAnsiEncoding
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-LtCnO
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-LtCnO
       Flags: Nonsymbolic, Italic
       FontBBox: -173, -272, 1066, 927
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-Bd
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-Bd
       Flags: Nonsymbolic
       FontBBox: -166, -218, 1078, 975
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-HvEx
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-HvEx
       Flags: Nonsymbolic
       FontBBox: -200, -223, 1297, 999
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-Roman
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-Roman
       Flags: Nonsymbolic
       FontBBox: -166, -214, 1076, 952
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: ZapfDingbatsStd
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: ZapfDingbatsStd
       Flags: Symbolic
       FontBBox: -1, -143, 981, 820
       FontFile3: true
      EncodingDictionary: 
       BaseEncoding: WinAnsiEncoding
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-Lt
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-Lt
       Flags: Nonsymbolic
       FontBBox: -166, -214, 1050, 967
       FontFile3: true
      EncodingDictionary: 
       BaseEncoding: WinAnsiEncoding
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-Md
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-Md
       Flags: Nonsymbolic
       FontBBox: -165, -221, 1066, 952
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-MdEx
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-MdEx
       Flags: Nonsymbolic
       FontBBox: -172, -220, 1159, 978
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-Hv
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-Hv
       Flags: Nonsymbolic
       FontBBox: -169, -234, 1096, 951
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-BdEx
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-BdEx
       Flags: Nonsymbolic
       FontBBox: -145, -213, 1163, 984
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-LtIt
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-LtIt
       Flags: Nonsymbolic, Italic
       FontBBox: -165, -214, 1099, 951
       FontFile3: true
      EncodingDictionary: 
       BaseEncoding: WinAnsiEncoding
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-BdCnO
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-BdCnO
       Flags: Nonsymbolic, Italic
       FontBBox: -171, -271, 1116, 961
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: HelveticaNeueLTStd-Ex
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: HelveticaNeueLTStd-Ex
       Flags: Nonsymbolic
       FontBBox: -157, -220, 1160, 963
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: SabonLTStd-Roman
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: SabonLTStd-Roman
       Flags: Serif, Nonsymbolic
       FontBBox: -165, -228, 1000, 944
       FontFile3: true
      EncodingDictionary: 
       BaseEncoding: WinAnsiEncoding
       Differences: true
      ToUnicode: true
     Font: 
      BaseFont: SabonLTStd-Bold
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: SabonLTStd-Bold
       Flags: Serif, Nonsymbolic
       FontBBox: -163, -228, 1000, 968
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
     Font: 
      BaseFont: SabonLTStd-Italic
      FirstChar: 0
      LastChar: 255
      FontDescriptor: 
       FontName: SabonLTStd-Italic
       Flags: Serif, Nonsymbolic, Italic
       FontBBox: -146, -228, 1059, 927
       FontFile3: true
      Encoding: WinAnsiEncoding
      ToUnicode: true
   XMP: <x:xmpmeta xmlns:x="adobe:ns:meta/" x:xmptk="Adobe XMP Core 6.0-c002 79.164460, 2020/05/12-16:04:17        ">
   <rdf:RDF xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#">
      <rdf:Description rdf:about=""
            xmlns:dc="http://purl.org/dc/elements/1.1/"
            xmlns:xmp="http://ns.adobe.com/xap/1.0/"
            xmlns:xmpMM="http://ns.adobe.com/xap/1.0/mm/"
            xmlns:stRef="http://ns.adobe.com/xap/1.0/sType/ResourceRef#"
            xmlns:stEvt="http://ns.adobe.com/xap/1.0/sType/ResourceEvent#"
            xmlns:xmpRights="http://ns.adobe.com/xap/1.0/rights/"
            xmlns:pdf="http://ns.adobe.com/pdf/1.3/"
            xmlns:ExtensisFontSense="http://www.extensis.com/meta/FontSense/">
         <dc:format>application/pdf</dc:format>
         <dc:title>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">Pediatric Liver and Kidney Transplant Recipients Demonstrate Greater Serological Response to SARS-CoV-2 Vaccination Than Adults</rdf:li>
            </rdf:Alt>
         </dc:title>
         <dc:creator>
            <rdf:Seq>
               <rdf:li>Tobias Laue </rdf:li>
               <rdf:li> Maria Pilar Ballester </rdf:li>
               <rdf:li> Lily Meoli </rdf:li>
               <rdf:li> Carl Grabitz </rdf:li>
               <rdf:li> Eva Uson </rdf:li>
               <rdf:li> Lorenzo D´Antiga </rdf:li>
               <rdf:li> Valerie McLin </rdf:li>
               <rdf:li> Montserrat Pujadas </rdf:li>
               <rdf:li> Ângela Carvalho-Gomes </rdf:li>
               <rdf:li> Ivan Sahuco</rdf:li>
               <rdf:li> Ariadna Bono</rdf:li>
               <rdf:li> Federico D'Amico </rdf:li>
               <rdf:li> Raffaela Viganò</rdf:li>
               <rdf:li> Elena Diago</rdf:li>
               <rdf:li> Beatriz Tormo Lanseros</rdf:li>
               <rdf:li> Elvira Inglese</rdf:li>
               <rdf:li> Dani Martinez Vazquez</rdf:li>
               <rdf:li> Annelotte Broekhoven</rdf:li>
               <rdf:li> Marjolein Kikkert </rdf:li>
               <rdf:li> Shessy P. Torres Morales </rdf:li>
               <rdf:li> Sebenzile K. Myeni </rdf:li>
               <rdf:li> Mar Riveiro-Barciela </rdf:li>
               <rdf:li> Adriana Palom </rdf:li>
               <rdf:li> Nicola Zeni</rdf:li>
               <rdf:li> Alessandra Brocca</rdf:li>
               <rdf:li> Annarosa Cussigh</rdf:li>
               <rdf:li> Sara Cmet </rdf:li>
               <rdf:li> Maria Desamparados Escudero-García </rdf:li>
               <rdf:li> Matteo Stocco </rdf:li>
               <rdf:li> Leonardo Antonio Natola</rdf:li>
               <rdf:li> Donatella Ieluzzi</rdf:li>
               <rdf:li> Veronica Paon</rdf:li>
               <rdf:li> Angelo Sangiovanni </rdf:li>
               <rdf:li> Elisa Farina </rdf:li>
               <rdf:li> Clara Dibenedetto </rdf:li>
               <rdf:li> Yolanda Sánchez-Torrijos </rdf:li>
               <rdf:li> Ana Lucena-Varela </rdf:li>
               <rdf:li> Eva Román </rdf:li>
               <rdf:li> Elisabet Sánchez</rdf:li>
               <rdf:li> Rubén Sánchez-Aldehuelo </rdf:li>
               <rdf:li> Julia López-Cardona </rdf:li>
               <rdf:li> Dhaarica Jeyanesan </rdf:li>
               <rdf:li> Alejandro Esquivel Morocho </rdf:li>
               <rdf:li> Itzel Canas-Perez</rdf:li>
               <rdf:li> Christine Eastgate </rdf:li>
               <rdf:li> Simone Di Cola </rdf:li>
               <rdf:li> Lucia Lapenna </rdf:li>
               <rdf:li> Giacomo Zaccherini </rdf:li>
               <rdf:li> Deborah Bongiovanni </rdf:li>
               <rdf:li> Antonio Riva </rdf:li>
               <rdf:li> Rajni Sharma </rdf:li>
               <rdf:li> Hio Lam Phoebe Tsou </rdf:li>
               <rdf:li> Nicola Harris</rdf:li>
               <rdf:li> Paola Zanaga</rdf:li>
               <rdf:li> Katia Sayaf </rdf:li>
               <rdf:li> Sabir Hossain </rdf:li>
               <rdf:li> Javier Crespo </rdf:li>
               <rdf:li> Mercedes Robles-Díaz </rdf:li>
               <rdf:li> Antonio Madejón </rdf:li>
               <rdf:li> Helena Degroote </rdf:li>
               <rdf:li> Marko Korenjak</rdf:li>
               <rdf:li> Xavier Verhelst </rdf:li>
               <rdf:li> Javier García-Samaniego </rdf:li>
               <rdf:li> Raúl J. Andrade </rdf:li>
               <rdf:li> Paula Iruzubieta</rdf:li>
               <rdf:li> Gavin Wright </rdf:li>
               <rdf:li> Paolo Caraceni </rdf:li>
               <rdf:li> Manuela Merli </rdf:li>
               <rdf:li> Vishal C. Patel </rdf:li>
               <rdf:li> Amir Gander </rdf:li>
               <rdf:li> Agustín Albillos </rdf:li>
               <rdf:li> Germán Soriano </rdf:li>
               <rdf:li> Maria Francesca Donato </rdf:li>
               <rdf:li> David Sacerdoti</rdf:li>
               <rdf:li> Pierluigi Toniutto </rdf:li>
               <rdf:li> Maria Buti </rdf:li>
               <rdf:li> Christophe Duvoux </rdf:li>
               <rdf:li> Paolo Antonio Grossi </rdf:li>
               <rdf:li> Thomas Berg</rdf:li>
               <rdf:li> Wojciech G. Polak </rdf:li>
               <rdf:li> Massimo Puoti</rdf:li>
               <rdf:li> Anna Bosch-Comas </rdf:li>
               <rdf:li> Luca S. Belli</rdf:li>
               <rdf:li> Patrizia Burra </rdf:li>
               <rdf:li> Francesco Paolo Russo </rdf:li>
               <rdf:li> Minneke Coenraad </rdf:li>
               <rdf:li> José Luis Calleja</rdf:li>
               <rdf:li> Giovanni Perricone </rdf:li>
               <rdf:li> Shilpa Chokshi </rdf:li>
               <rdf:li> Marina Berenguer </rdf:li>
               <rdf:li> Joan Clària </rdf:li>
               <rdf:li> Richard Moreau </rdf:li>
               <rdf:li> Javier Fernández </rdf:li>
               <rdf:li> Vicente Arroyo </rdf:li>
               <rdf:li> Paolo Angeli</rdf:li>
               <rdf:li> Cristina Sánchez-Garrido </rdf:li>
               <rdf:li> Javier Ampuero </rdf:li>
               <rdf:li> Salvatore Piano </rdf:li>
               <rdf:li> Emanuele Nicastro </rdf:li>
               <rdf:li> Nathalie Rock </rdf:li>
               <rdf:li> Debbie Shawcross </rdf:li>
               <rdf:li> Lindsey Edwards </rdf:li>
               <rdf:li> Frauke Mutschler </rdf:li>
               <rdf:li> Anette Melk </rdf:li>
               <rdf:li> Gautam Mehta </rdf:li>
               <rdf:li> Ulrich Baumann </rdf:li>
               <rdf:li> Rajiv Jalan </rdf:li>
            </rdf:Seq>
         </dc:creator>
         <dc:subject>
            <rdf:Bag>
               <rdf:li/>
            </rdf:Bag>
         </dc:subject>
         <dc:description>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">DOI: 10.1097/TXD.0000000000001787&#xD;Transplantation Direct, Volume. 11, Issue. 5, 29 April 2025&#xD;Background. Adult solid organ transplant recipients (SOTRs) have decreased responsiveness to severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) vaccination and higher incidence of infection, but there are few data on the serological response in pediatric SOTR. The aim of this study was to determine serological response to SARS-CoV-2 vaccination in pediatric liver (LT) and kidney transplant (KT) recipients and compare it with adult SOTR. Methods. A European, prospective, multicenter study was performed. Samples were taken at 7 and 32 wk following COVID-19 vaccination and serological endpoints were measured by ELISA. Results. A total of 42 pediatric (16 post-LT and 26 post-KT) and 117 adult (all post-LT) were included. All pediatric participants and 94% adult participants received mRNA vaccines. Paediatric SOTR patients had significantly higher anti-Spike IgG levels than adult participants at week 7 (114 220.7 [59 285.92–220 058.55] versus 8756.7 [5643.69–13 586.71], P &lt; 0.0001) and week 32 (46 113.2 [10 992.91–193 436.14] versus 8207.0 [3561.20–18 913.43], P = 0.0032). No significant difference in week 7 anti-Spike IgG response was found between pediatric LT and KT (129 434.4 [51 888.64–322 869.69] versus 105 304.5 [39 910.20–277 849.50], P = 0.9854). No differences were seen between children and adults in the rate of decline of anti-Spike IgG between weeks 7 and 32 (P = 0.8000). Male sex and hemolytic-uremic syndrome or postischemic kidney disease were associated with lower anti-Spike IgG levels at week 7 in pediatric SOTR. Conclusions. Paediatric SOTR demonstrate greater SARS-CoV-2 vaccine responses than comparable adult SOTR patients. These data support efficacy and safety of SARS-CoV-2 vaccination in child SOTR and may alleviate vaccine hesitancy in this patient group. </rdf:li>
            </rdf:Alt>
         </dc:description>
         <dc:rights>
            <rdf:Alt>
               <rdf:li xml:lang="x-default">Copyright © 2025 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.</rdf:li>
            </rdf:Alt>
         </dc:rights>
         <xmp:CreateDate>2025-04-29T13:00:15+05:30</xmp:CreateDate>
         <xmp:MetadataDate>2025-04-29T13:00:17+05:30</xmp:MetadataDate>
         <xmp:ModifyDate>2025-04-29T13:00:17+05:30</xmp:ModifyDate>
         <xmp:CreatorTool>Adobe InDesign 15.1 (Windows)</xmp:CreatorTool>
         <xmpMM:InstanceID>uuid:520ec277-0994-44f8-92d6-c649a0f3dfeb</xmpMM:InstanceID>
         <xmpMM:OriginalDocumentID>xmp.did:07801174072068118C149D4CFFA16D8F</xmpMM:OriginalDocumentID>
         <xmpMM:DocumentID>xmp.id:d0fcfa38-6db8-9340-8319-cf1f5515d27f</xmpMM:DocumentID>
         <xmpMM:RenditionClass>proof:pdf</xmpMM:RenditionClass>
         <xmpMM:DerivedFrom rdf:parseType="Resource">
            <stRef:instanceID>xmp.iid:927cbce4-b5e9-554b-b2ee-484b4fd77819</stRef:instanceID>
            <stRef:documentID>xmp.did:928513a0-8c66-a043-9ea8-d107a0175223</stRef:documentID>
            <stRef:originalDocumentID>xmp.did:07801174072068118C149D4CFFA16D8F</stRef:originalDocumentID>
            <stRef:renditionClass>default</stRef:renditionClass>
         </xmpMM:DerivedFrom>
         <xmpMM:History>
            <rdf:Seq>
               <rdf:li rdf:parseType="Resource">
                  <stEvt:action>converted</stEvt:action>
                  <stEvt:parameters>from application/x-indesign to application/pdf</stEvt:parameters>
                  <stEvt:softwareAgent>Adobe InDesign 15.1 (Windows)</stEvt:softwareAgent>
                  <stEvt:changed>/</stEvt:changed>
                  <stEvt:when>2025-04-29T13:00:15+05:30</stEvt:when>
               </rdf:li>
            </rdf:Seq>
         </xmpMM:History>
         <xmpRights:Marked>True</xmpRights:Marked>
         <pdf:Producer>Adobe PDF Library 15.0</pdf:Producer>
         <pdf:Trapped>False</pdf:Trapped>
         <ExtensisFontSense:slug>
            <rdf:Bag>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.102</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>29160</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>54270</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>3961400679</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-Bold</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>3961400679</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.001</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>29368</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>49047</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>2545333180</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-LightItalic</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>2545333180</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.001</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>28993</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>54247</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>694711820</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-Light</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>694711820</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.000</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>29135</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>47095</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>918152097</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-Extended</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>918152097</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.001</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>30079</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>57122</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>4026944685</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-Heavy</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>4026944685</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.101</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>28152</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>54890</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>1503573258</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-Roman</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>1503573258</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.001</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>29269</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>55034</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>693512647</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-Medium</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>693512647</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Helvetica Neue</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.000</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>29681</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>48355</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>3496363321</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>HelveticaNeue-MediumExt</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>3496363321</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Sabon</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.000</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>50128</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>59760</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>488753164</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>Sabon-Roman</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>488753164</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Symbol</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>001.008</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>35753</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>0</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Adobe Systems</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>PostScript</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>3697362657</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>Symbol</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>3697362657</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
               <rdf:li rdf:parseType="Resource">
                  <ExtensisFontSense:Family>Zapf Dingbats</ExtensisFontSense:Family>
                  <ExtensisFontSense:Version>6.0</ExtensisFontSense:Version>
                  <ExtensisFontSense:OutlineFileSize>0</ExtensisFontSense:OutlineFileSize>
                  <ExtensisFontSense:KerningChecksum>0</ExtensisFontSense:KerningChecksum>
                  <ExtensisFontSense:Foundry>Galapagos Design Group</ExtensisFontSense:Foundry>
                  <ExtensisFontSense:FontKind>TrueType</ExtensisFontSense:FontKind>
                  <ExtensisFontSense:Checksum>809606256</ExtensisFontSense:Checksum>
                  <ExtensisFontSense:PostScriptName>ZapfDingbatsITC</ExtensisFontSense:PostScriptName>
                  <ExtensisFontSense:FontSense_1.2_Checksum>809606256</ExtensisFontSense:FontSense_1.2_Checksum>
               </rdf:li>
            </rdf:Bag>
         </ExtensisFontSense:slug>
      </rdf:Description>
   </rdf:RDF>
</x:xmpmeta>
   Pages: 
    Page: 
     Sequence: 1
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 88, 609, 100, 597
      Annotation: 
       Subtype: Link
       Rect: 123, 609, 126, 596
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 128, 609, 131, 596
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 269, 609, 269, 596
      Annotation: 
       Subtype: Link
       Rect: 272, 609, 275, 596
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 371, 609, 371, 596
      Annotation: 
       Subtype: Link
       Rect: 374, 609, 377, 596
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 455, 609, 455, 596
      Annotation: 
       Subtype: Link
       Rect: 458, 609, 462, 596
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 104, 597, 104, 584
      Annotation: 
       Subtype: Link
       Rect: 107, 597, 110, 584
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 188, 597, 200, 585
      Annotation: 
       Subtype: Link
       Rect: 220, 597, 220, 584
      Annotation: 
       Subtype: Link
       Rect: 223, 597, 226, 584
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 330, 597, 330, 584
      Annotation: 
       Subtype: Link
       Rect: 333, 597, 337, 584
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 453, 597, 453, 584
      Annotation: 
       Subtype: Link
       Rect: 456, 597, 459, 584
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 171, 585, 171, 572
      Annotation: 
       Subtype: Link
       Rect: 174, 585, 178, 572
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 179, 585, 183, 572
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 244, 585, 248, 572
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 315, 585, 319, 572
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 428, 585, 428, 572
      Annotation: 
       Subtype: Link
       Rect: 431, 585, 437, 572
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 439, 585, 446, 572
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 108, 573, 115, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 175, 573, 182, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 183, 573, 190, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 192, 573, 199, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 311, 573, 318, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 320, 573, 326, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 388, 573, 395, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 506, 573, 513, 560
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 138, 561, 145, 548
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 248, 561, 248, 548
      Annotation: 
       Subtype: Link
       Rect: 250, 561, 257, 548
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 399, 561, 399, 548
      Annotation: 
       Subtype: Link
       Rect: 402, 561, 409, 548
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 149, 549, 156, 536
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 299, 549, 306, 536
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 308, 549, 315, 536
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 316, 549, 323, 536
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 417, 549, 417, 536
      Annotation: 
       Subtype: Link
       Rect: 420, 549, 427, 536
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 429, 549, 435, 536
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 491, 549, 498, 536
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 118, 537, 124, 524
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 207, 537, 213, 524
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 287, 537, 287, 524
      Annotation: 
       Subtype: Link
       Rect: 289, 537, 296, 524
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 507, 537, 507, 524
      Annotation: 
       Subtype: Link
       Rect: 510, 537, 513, 524
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 515, 537, 521, 524
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 156, 525, 156, 512
      Annotation: 
       Subtype: Link
       Rect: 159, 525, 162, 512
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 281, 525, 287, 512
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 365, 525, 372, 512
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 443, 525, 450, 512
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 143, 513, 143, 500
      Annotation: 
       Subtype: Link
       Rect: 146, 513, 152, 500
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 228, 513, 228, 500
      Annotation: 
       Subtype: Link
       Rect: 231, 513, 237, 500
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 340, 513, 340, 500
      Annotation: 
       Subtype: Link
       Rect: 343, 513, 350, 500
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 508, 513, 508, 500
      Annotation: 
       Subtype: Link
       Rect: 511, 513, 517, 500
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 142, 501, 142, 488
      Annotation: 
       Subtype: Link
       Rect: 145, 501, 152, 488
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 232, 501, 232, 488
      Annotation: 
       Subtype: Link
       Rect: 235, 501, 242, 488
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 244, 501, 250, 488
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 252, 501, 259, 488
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 342, 501, 349, 488
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 350, 501, 357, 488
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 502, 501, 502, 488
      Annotation: 
       Subtype: Link
       Rect: 505, 501, 512, 488
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 151, 489, 151, 476
      Annotation: 
       Subtype: Link
       Rect: 154, 489, 161, 476
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 290, 489, 290, 476
      Annotation: 
       Subtype: Link
       Rect: 293, 489, 296, 476
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 445, 489, 445, 476
      Annotation: 
       Subtype: Link
       Rect: 448, 489, 451, 476
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 117, 477, 124, 464
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 266, 477, 266, 464
      Annotation: 
       Subtype: Link
       Rect: 269, 477, 276, 464
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 370, 477, 370, 464
      Annotation: 
       Subtype: Link
       Rect: 373, 477, 380, 464
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 471, 477, 471, 464
      Annotation: 
       Subtype: Link
       Rect: 474, 477, 481, 464
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 173, 465, 173, 452
      Annotation: 
       Subtype: Link
       Rect: 176, 465, 183, 452
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 184, 465, 191, 452
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 317, 465, 317, 452
      Annotation: 
       Subtype: Link
       Rect: 320, 465, 326, 452
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 513, 465, 513, 452
      Annotation: 
       Subtype: Link
       Rect: 515, 465, 522, 452
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 121, 453, 121, 440
      Annotation: 
       Subtype: Link
       Rect: 124, 453, 131, 440
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 292, 453, 292, 440
      Annotation: 
       Subtype: Link
       Rect: 295, 453, 302, 440
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 365, 453, 372, 440
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 440, 453, 447, 440
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 448, 453, 455, 440
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 113, 441, 113, 428
      Annotation: 
       Subtype: Link
       Rect: 116, 441, 123, 428
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 124, 441, 131, 428
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 317, 441, 317, 428
      Annotation: 
       Subtype: Link
       Rect: 320, 441, 327, 428
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 439, 441, 439, 428
      Annotation: 
       Subtype: Link
       Rect: 442, 441, 449, 428
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 451, 441, 457, 428
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 185, 429, 185, 416
      Annotation: 
       Subtype: Link
       Rect: 188, 429, 195, 416
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 196, 429, 203, 416
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 311, 429, 311, 416
      Annotation: 
       Subtype: Link
       Rect: 314, 429, 321, 416
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 450, 429, 450, 416
      Annotation: 
       Subtype: Link
       Rect: 452, 429, 459, 416
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 461, 429, 468, 416
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 109, 417, 116, 404
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 232, 417, 232, 404
      Annotation: 
       Subtype: Link
       Rect: 235, 417, 241, 404
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 243, 417, 250, 404
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 252, 417, 259, 404
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 422, 417, 422, 404
      Annotation: 
       Subtype: Link
       Rect: 425, 417, 431, 404
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 155, 405, 155, 392
      Annotation: 
       Subtype: Link
       Rect: 158, 405, 165, 392
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 167, 405, 173, 392
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 251, 405, 258, 392
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 259, 405, 266, 392
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 418, 405, 418, 392
      Annotation: 
       Subtype: Link
       Rect: 421, 405, 428, 392
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 126, 393, 126, 380
      Annotation: 
       Subtype: Link
       Rect: 129, 393, 136, 380
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 137, 393, 144, 380
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 232, 393, 232, 380
      Annotation: 
       Subtype: Link
       Rect: 234, 393, 241, 380
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 307, 393, 320, 381
      Annotation: 
       Subtype: Link
       Rect: 374, 393, 374, 380
      Annotation: 
       Subtype: Link
       Rect: 377, 393, 380, 380
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 382, 393, 389, 380
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 498, 393, 498, 380
      Annotation: 
       Subtype: Link
       Rect: 501, 393, 508, 380
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 151, 381, 151, 368
      Annotation: 
       Subtype: Link
       Rect: 154, 381, 160, 368
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 259, 381, 259, 368
      Annotation: 
       Subtype: Link
       Rect: 262, 381, 269, 368
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 270, 381, 277, 368
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 413, 381, 413, 368
      Annotation: 
       Subtype: Link
       Rect: 415, 381, 422, 368
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 500, 381, 506, 368
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 129, 369, 129, 356
      Annotation: 
       Subtype: Link
       Rect: 132, 369, 139, 356
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 233, 369, 233, 356
      Annotation: 
       Subtype: Link
       Rect: 236, 369, 243, 356
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 245, 369, 252, 356
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 362, 369, 362, 356
      Annotation: 
       Subtype: Link
       Rect: 364, 369, 371, 356
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 515, 369, 515, 356
      Annotation: 
       Subtype: Link
       Rect: 517, 369, 524, 356
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 99, 357, 106, 344
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 239, 357, 239, 344
      Annotation: 
       Subtype: Link
       Rect: 242, 357, 249, 344
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 321, 357, 328, 344
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 448, 357, 448, 344
      Annotation: 
       Subtype: Link
       Rect: 451, 357, 454, 344
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 516, 357, 523, 344
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 143, 345, 143, 332
      Annotation: 
       Subtype: Link
       Rect: 146, 345, 153, 332
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 154, 345, 161, 332
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 318, 345, 318, 332
      Annotation: 
       Subtype: Link
       Rect: 321, 345, 328, 332
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 330, 345, 337, 332
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 472, 345, 472, 332
      Annotation: 
       Subtype: Link
       Rect: 475, 345, 482, 332
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 114, 333, 120, 320
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 122, 333, 129, 320
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 239, 333, 239, 320
      Annotation: 
       Subtype: Link
       Rect: 242, 333, 248, 320
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 344, 333, 344, 320
      Annotation: 
       Subtype: Link
       Rect: 347, 333, 354, 320
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 355, 333, 362, 320
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 466, 333, 466, 320
      Annotation: 
       Subtype: Link
       Rect: 469, 333, 473, 320
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 474, 333, 478, 320
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 111, 321, 111, 308
      Annotation: 
       Subtype: Link
       Rect: 114, 321, 118, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 119, 321, 126, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 223, 321, 223, 308
      Annotation: 
       Subtype: Link
       Rect: 226, 321, 229, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 231, 321, 238, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 239, 321, 246, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 373, 321, 373, 308
      Annotation: 
       Subtype: Link
       Rect: 376, 321, 379, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 381, 321, 388, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 503, 321, 503, 308
      Annotation: 
       Subtype: Link
       Rect: 506, 321, 510, 308
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 92, 309, 99, 296
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 237, 309, 237, 296
      Annotation: 
       Subtype: Link
       Rect: 240, 309, 243, 296
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 386, 309, 386, 296
      Annotation: 
       Subtype: Link
       Rect: 389, 309, 395, 296
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 512, 309, 512, 296
      Annotation: 
       Subtype: Link
       Rect: 514, 309, 521, 296
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 205, 297, 205, 284
      Annotation: 
       Subtype: Link
       Rect: 208, 297, 215, 284
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 301, 297, 301, 284
      Annotation: 
       Subtype: Link
       Rect: 304, 297, 307, 284
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 512, 297, 512, 284
      Annotation: 
       Subtype: Link
       Rect: 515, 297, 522, 284
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 237, 285, 237, 272
      Annotation: 
       Subtype: Link
       Rect: 240, 285, 247, 272
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 348, 285, 348, 272
      Annotation: 
       Subtype: Link
       Rect: 351, 285, 355, 272
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 458, 285, 458, 272
      Annotation: 
       Subtype: Link
       Rect: 461, 285, 465, 272
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 162, 273, 169, 260
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 171, 273, 177, 260
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 274, 273, 274, 260
      Annotation: 
       Subtype: Link
       Rect: 277, 273, 280, 260
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 282, 273, 289, 260
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 407, 273, 407, 260
      Annotation: 
       Subtype: Link
       Rect: 407, 273, 410, 260
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 412, 273, 419, 260
       ActionDest: 11
      Annotation: 
       Subtype: Link
       Rect: 420, 273, 427, 260
       ActionDest: 11
    Page: 
     Sequence: 2
    Page: 
     Sequence: 3
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 136, 558, 139, 547
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 140, 558, 143, 547
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 141, 547, 144, 536
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 146, 547, 149, 536
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 65, 503, 68, 492
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 69, 503, 72, 492
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 180, 492, 182, 481
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 230, 481, 233, 470
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 208, 459, 211, 448
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 212, 459, 218, 448
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 267, 437, 273, 426
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 111, 404, 117, 393
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 501, 569, 507, 558
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 509, 569, 515, 558
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 384, 536, 390, 525
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 519, 525, 525, 514
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 511, 492, 517, 481
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 519, 492, 525, 481
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 328, 298, 331, 287
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 470, 298, 503, 287
       ActionDest: 12
      Annotation: 
       Subtype: Link
       Rect: 193, 149, 273, 141
      Annotation: 
       Subtype: Link
       Rect: 36, 140, 49, 132
      Annotation: 
       Subtype: Link
       Rect: 251, 121, 273, 113
      Annotation: 
       Subtype: Link
       Rect: 36, 112, 62, 104
      Annotation: 
       Subtype: Link
       Rect: 249, 91, 273, 83
      Annotation: 
       Subtype: Link
       Rect: 36, 82, 161, 74
    Page: 
     Sequence: 4
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 409, 327, 439, 317
       ActionDest: 14
      Annotation: 
       Subtype: Link
       Rect: 439, 70, 479, 60
       ActionDest: 15
    Page: 
     Sequence: 5
    Page: 
     Sequence: 6
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 85, 333, 124, 322
       ActionDest: 15
      Annotation: 
       Subtype: Link
       Rect: 235, 289, 267, 278
       ActionDest: 16
      Annotation: 
       Subtype: Link
       Rect: 227, 267, 265, 256
       ActionDest: 16
      Annotation: 
       Subtype: Link
       Rect: 136, 212, 174, 201
       ActionDest: 16
      Annotation: 
       Subtype: Link
       Rect: 161, 147, 190, 136
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 401, 300, 429, 289
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 444, 91, 450, 80
       ActionDest: 18
    Page: 
     Sequence: 7
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 209, 167, 215, 156
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 216, 167, 222, 156
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 257, 134, 263, 123
       ActionDest: 18
      Annotation: 
       Subtype: Link
       Rect: 239, 79, 242, 68
       ActionDest: 17
      Annotation: 
       Subtype: Link
       Rect: 151, 46, 157, 35
       ActionDest: 18
    Page: 
     Sequence: 8
    Page: 
     Sequence: 9
     Annotations: 
      Annotation: 
       Subtype: Link
       Rect: 180, 712, 273, 704
      Annotation: 
       Subtype: Link
       Rect: 51, 703, 271, 695
      Annotation: 
       Subtype: Link
       Rect: 250, 676, 273, 668
      Annotation: 
       Subtype: Link
       Rect: 51, 667, 273, 659
      Annotation: 
       Subtype: Link
       Rect: 51, 658, 178, 650
  Checksum: af569954
   Type: CRC32
  Checksum: 4020bfd52e52edeeb983f35806040fab
   Type: MD5
  Checksum: ca85192307f284820ac421a5d968e4ad47d2c055
   Type: SHA-1
  Checksum: fde0f78d191b3aa49a64fc6ffc9b5cb5892b606cb896fca4e1f0a9ec511f187c
   Type: SHA-256