See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/263739999

Who and What Drove Walter Kempner? The Rice Diet Revisited

Article in Hypertension · July 2014

DOI: 10.1161/HYPERTENSIONAHA.114.03946 · Source: PubMed

CITATIONS READS

17 7,036

3 authors, including:

Philip J Klemmer Clarence Grim

University of North Carolina at Chapel Hill 309 PUBLICATIONS 11,047 CITATIONS
54 PUBLICATIONS 2,478 CITATIONS
SEE PROFILE
SEE PROFILE

Some of the authors of this publication are also working on these related projects:

The effects of selective survival during starvation on BP/DM today View project

Blood pressure measurement View project

All content following this page was uploaded by Clarence Grim on 19 March 2019.

The user has requested enhancement of the downloaded file.

 Hypertension Grand Rounds

Who and What Drove Walter Kempner?

The Rice Diet Revisited
Philip Klemmer, Clarence E. Grim, Friedrich C. Luft

T he refugee with the strong German accent explained his

ideas about renal failure to his skeptical medical students.
“The problem with renal failure is the resultant metabolic dys-
bilaterally. The neck veins were distended, and the breath
sounds were diminished bilaterally in an area where dullness
was increased; above the lung bases, rales were audible. A third
function. The kidneys excrete waste products, amino acids, heart sound was apparent. The liver was enlarged, and copi-
keto-acid metabolites, hydrogen ions, the salt that is eaten, and ous (4+) peripheral edema was evident. The protein excretion
all these things are the result of what the people are eating. was >1.5 g per day. Phenothalein excretion after intravenous
Theoretically, we should be able to make them better by reduc- injection was diminished. The nonprotein nitrogen concentra-
ing the amount of work the kidneys have to do. Namely, we tion was increased; the hematocrit was decreased as were the
could radically alter the patients’ diets and thereby save lives.” plasma proteins.
The (Duke University) students challenged the Herr Professor.
“Sounds cool but prove it!” And so he did. The ideas behind What Is to be Done With Such a Patient
this gallant hypothesis were not that novel. Others had pre- (in 1939–1949 or Later)?
scribed various similar ideas about reducing renal work by Kempner, on the basis of his earlier cell metabolic studies
modifying the diet, particularly in terms of sodium content.1 and experiences in German departments of internal medicine,
However, they had not been that successful in sending the kid- adapted a regimen to comply with the medical students’ chal-
neys on vacation.2 Kempner introduced the first comprehen- lenge. The diet he designed consisted almost entirely of rice
sive (global) dietary program to treat chronic renal disease. By and fruit. The diet provided ≈2000 calories per day. Kempner
doing so, he revolutionized not only that disease but also the occasionally reluctantly permitted addition of breads or treats.
treatment of hypertension, obesity, and a host of other disor- In essence, the diet comprised 4% to 5% protein (<20 g per
ders.3 Furthermore, perhaps unintentionally he raised the issue day), 2% to 3% fat, and the rest was complex carbohydrates.
of lifestyle, because following his regimen required a change The sodium content was 150 mg (<10 mmol/d). Fluid intake
in just that. His own contribution, the Kempner name, the times per day was restricted. Kempner was aware that white rice
in Germany and elsewhere, the environment, the technical might be thiamine deficient and included a vitamin prepara-
advances, and the driving force behind a young medical faculty tion. He also included citrate-containing fruit juices with the
and its visionary leaders should not be forgotten. The ideas that idea that any metabolic acidosis could be counteracted that
Kempner left us have been archived by remarkable associates way. If we compare that regimen with the US diet of then (and
and contemporaries, whose memories, such as Newborg4 and now), we observe 25% protein, 25% fat, and 50% carbohy-
Stead,5 guide us in terms of our current interpretations. Without drates. Furthermore, the daily salt intake would entail ≈9 g
them, we would have missed much of Kempner’s work, and (Na+ and Cl−, 150–160 mmol). Thus, the Kempner diet was
some of us would have had less tachycardia at grand rounds.6 (dramatically) low in salt (Na+, ≈10 mmol/d), low in protein
(<20 g/d), low in fat, and high in complex carbohydrates.
The Case Kempner was interested in winning the clinical battle, less in
The 49-year-old diabetic hypertensive patient was admitted which constituent (salt, calories, protein, carbohydrates, or
to Duke University Hospital because of shortness of breath. fats) was the most important regarding any particular separate
His family members had died mostly of myocardial infarc- effects. Results from this patient are shown in Figure 1.
tion and stroke. Renal failure was also in the family history, Our interests here are multiple. Obviously, the dietary
albeit irrelevant because there was no treatment then available. intervention is provocative, although others had grasped after
The patient had been overweight all his life. The admitting this brass ring earlier.1 Furthermore, have current medical
blood pressure was 200/130 mm Hg. Examination disclosed advances made such dramatic dietary interventions irrelevant?
papilledema and malignant hypertensive eye ground changes Finally, what was the driving force in the method of thought

Received May 25, 2014; first decision May 31, 2014; revision accepted June 18, 2014.
From the Nephrology Section, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill (P.K.); Department of Medicine,
Medical College of Wisconsin, Milwaukee (C.E.G.); and Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrück Center
for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany (F.C.L.).
Correspondence to Friedrich C. Luft, Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrück Center for Molecular
Medicine and the Charité Medical Faculty, Lindenbergerweg 80, 13125 Berlin, Germany. E-mail luft@charite.de
(Hypertension. 2014;64:684-688.)
© 2014 American Heart Association, Inc.
Hypertension is available at http://hyper.ahajournals.org DOI: 10.1161/HYPERTENSIONAHA.114.03946

684
Downloaded from http://hyper.ahajournals.org/ by guest on October 29, 2015
 Klemmer et al   Diet and Hypertension   685

Figure 1. Anecdotes do not make a summer. However, improvements in the cardiac silhouette, the ECG, and the ophthalmic retinal
photographs after initiation of diet cannot be denied.15

behind Walter Kempner that caused him to swim against the reasons were not solely related to his medical studies.
stream? The German poet Stefan George (1868–1933) fascinated
Kempner. George was at the center of an influential liter-
Discussion ary and academic circle known as the George-Kreis that
Kempner and New Dahlem included many of the young leading writers and intellectu-
Walter Kempner (1903–1997) was the third child of Walter als of the time. George and his writings were identified with
Kempner Sr and Lydia Rabinowitsch-Kempner; they were the Conservative Revolutionary movement, which advocated
assimilated German Jews. His parents were both bacteriologists new conservatism and nationalism. The members based their
working on tuberculosis and were affiliated with Robert Koch ideas on organic rather than materialistic thinking, on quality
in Berlin. Kempner’s mother had been professor of pathol- rather than quantity, and promoted what they regarded to be
ogy at Women’s Medical College in Philadelphia. Kempner’s the productive power of modernity. The historian Fritz Stern
older brother, Robert, was a German-educated lawyer who stated that the movement was “a tribute to the genuine spiri-
left Germany over Italy to come to the United States. Robert tual quality of the conservative revolution—that the reality of
Kempner was the assistant to Robert Jackson, prosecutor of the Third Reich aroused many of them to opposition, some-
Nazi war criminals at Nürnberg. He returned to Germany after times silent, often open, and costly.”7 Claus von Stauffenberg,
the war, settled in Frankfurt, and prosecuted other Nazi war who conspired the plot against Hitler, was also a member of
criminals at the Wilhelmsstraße trials where he first presented the George-Kreis. Kempner befriended George, joined the
the Wannsee protocols as written, documenting premeditated Circle, and was instrumental in caring for the ailing poet until
evidence leading to the holocaust. Kempner’s older sister, the latter’s death in 1933. We think that Kempner’s participa-
Nadja, completed a PhD in German literature at the University tion in the George-Kreis influenced his thinking and character,
of Heidelberg but died tragically of tuberculosis thereafter, particularly regarding the zeal and creative stubbornness that
the disease that also claimed Kempner’s father. The Kempner Kempner later exhibited.
children grew up in pre–World War I Berlin in a prosperous, During his studies, Kempner made numerous friends who
intellectually rich, privileged family. The parents, although would be important to him throughout his life, some of whom
professionally busy, took time to assure excellent educations also eventually landed in Durham. Notable is Dr Clothilde
for their children. All attended superb preparatory schools Schlayer, who was also involved in the care of Stefan George.
(Gymnasium). Walter Kempner directed Antigone (Sophocles) Kempner graduated in 1928 and interned with Ludolf Krehl
as a high-school student to honor his favorite teacher. The pro- in Heidelberg. This superb clinical training was continued in
duction was conducted entirely in ancient Greek. Berlin when Kempner received further training from Gustav
Kempner began his medical studies in Berlin, but shortly von Bergmann. But the most important part of his postgraduate
thereafter transferred to the University of Heidelberg. The education was his time with the Nobel laureate Otto Warburg.
Downloaded from http://hyper.ahajournals.org/ by guest on October 29, 2015
686  Hypertension  October 2014

“Do you know any chemistry?” “No,” Kempner replied. “How The JAMA rejected the manuscript for publication, as did
about physics?” Another “No” followed. “We don’t have any Archives of Internal Medicine. However, North Carolina
room for you, but you can sit in the corner for a couple of Medical Journal published the work, demanding hefty page
weeks and watch if you wish,” Warburg replied. Off-and-on, charges.13–17 Kempner kept meticulous records including
Kempner spent 3 years with Warburg. Three scientists who roentgenograms, ECGs, and fundus photographs, collected
worked in Warburg’s laboratory, including Sir Hans Krebs, blood and urine, followed renal function (nonprotein nitro-
went on to win the Nobel Prize. Here, Kempner enjoyed a gen, creatinine, chloride excretion), and monitored glucose
superb education in metabolism. When the first anti-Jewish and serum cholesterol. The flame photometer would not make
laws were introduced in Germany in 1933, Kempner was dis- its appearance until the 1950s, and routine acid–base bal-
missed from any clinical positions and he began to look for ance (CO2 combining power) determination was only on the
work outside Germany. The road to Durham was not straight- horizon.
forward. Kempner was reluctant to leave Germany because The rice diet did not cure everybody. In Kempner’s original
many thought the Nazi spook could only be a transient state cohort of 192 people, 25 patients died. Of the remaining 167,
of affairs and that Germans would come to their senses. Thus, 60 patients did not substantially improve their blood pressure
an initial offer at Johns Hopkins was refused. By 1934, mat- values. However, 107 patients showed significant improve-
ters had deteriorated further. Dr Frederic Hanes (1883–1946), ment (from 200/112 mm Hg to 149/96 mm Hg) with the diet.
Chairman of Medicine, offered Kempner a 2-year contract. Heart size decreased in 66 of 72 patients. Serum cholesterol
The Rockefeller Institute that also funded Max-Delbrück was reduced in 73 of 82 patients. Retinopathy was reduced
assisted in the financing. or disappeared completely in 21 of 33 patients. We must
The Perlzweigs from the Biochemistry Department keep these results in context with the times, during which the
took Kempner in. Judith Perlzweig subsequently dutifully life expectancy of anyone with malignant hypertension was
reported: “His English was terrible, the vocabulary sub-basic, 6 months. Sympathectomy seemed to improve that state of
the grammar poor, the meaning obscured by an extraordi- affairs, but not in all patients. Understandably, improved and
narily heavy German accent. Kempner resolutely hacked out healed patients became zealous supporters of Kempner and
his sentences as if clearing a path through jungle undergrowth his cause. As a result, other physicians elsewhere adopted use
with a machete.” Nevertheless, he worked hard, also to secure of the rice diet. Kempner’s next noteworthy presentation was
the entry of Dr Clothilde Schlayer, who moved to Durham at the New York Academy of Medicine. Kempner successfully
to join his research on the Warburg apparatus. An impres- defended his report against attacks from skeptics. He pointed
sive series of articles quickly followed, sufficient to get the out that months might be necessary for success and defended
appointment extended.8–10 Kempner and Schlayer11 returned applicability in malignant hypertension, renal failure, heart
to Germany in 1935 to care for Kempner’s mother who was failure, and their combinations.17 An example from a patient
dying. It proved to be Kempner’s last trip to Germany. Back managed with best-available treatment at the time, well known
in Durham, Kempner and Schlayer continued work on cell to the authors, is shown in Figure 2.
metabolism also in bacterial cells. The quality of the work The rice diet was subsequently extended to patients with
was sufficient to garner an invitation to Cold Springs Harbor. nephrotic syndrome, hypercholesterolemia, diabetes mellitus,
In the mean time, Kempner battled his way to clinical licen- atherosclerosis, and subsequently obesity.16 And it worked,
sure. The North Carolinians were suspicious. But when one not in all patients but in many, for whom no other therapeu-
of his examiners asked Kempner, “where the best medicine tic options were open. There were numerous successes and
was practiced, in the United States or in Germany?” Kempner reports with the rice diet. In 1947, Eugene A. Stead Jr,5 the
adroitly answered: “The best medicine now practiced in the renowned clinician/scientist and medical educator mentioned
world is in North Carolina.” “You’re all right; you are our earlier, succeeded Frederic Hanes as Chief of Medicine at
man,” answered the convinced examiner. Duke University. Although William Osler is generally cred-
In addition to Clothilde Schlayer, Kempner successfully ited with defining the state and practice of clinical medicine
navigated other German expatriates to Durham, including earlier in the 19th century, few would dispute Dr Stead’s sub-
Ernst Peschel and Ruth Lohmann Peschel.12 The result was sequent importance as a pre-eminent medical educator of the
not only an ever-efficient clinical and laboratory team but 20th century.
also a small colony in Durham named after Dahlem, a suburb We cannot improve on Stead’s commentary.18 We include
of Berlin from where Kempner came and where Warburg’s a brief summary of his poignant comments: “All dieters are
institute was located. Kempner also captured American talent, liars and therefore substantiated 24-hour urine specimens
most notably, Barbara Newborg.3 (perhaps consecutive) are necessary.” Kempner restricted flu-
ids to avoid water intoxication (hyponatremia as obviated by
Rice Diet the flame photometer), showed that on the diet the patients
Recruiting patients for the rice diet was initially sluggish became insulin sensitive, demonstrated that the diet lowered
but gained momentum as successes mounted. The data were serum cholesterol, and provided efficacy in renal disease–
first presented nationwide in Chicago at the 1944 American inducing salt-retention states (nephrotic syndrome), and the
Medical Association convention. The audience was stunned. triumph was for malignant hypertension.
However, skeptical physicians accused Kempner of revers- Stead pointed out that Kempner did not appeal to the
ing the dates on the chest roentgenograms and ECGs, thereby scientific community. The community wanted evidence-
implying fraud. “Those damn Yankees,” retorted Dr Hanes. based trials. Kempner argued that the prior state was the
Downloaded from http://hyper.ahajournals.org/ by guest on October 29, 2015
 Klemmer et al   Diet and Hypertension   687

Figure 2. Shown is not the same patient

as in Figure 1. We selected this example
because it exemplifies on the graph
to what the patients were subjected
pharmacologically. The patient evidently
had pulmonary edema because a strategy
well known to the authors was applied.15

comparator rather than a randomized control group. Of hypothesis,26 or discovered infradian rhythms in sodium bal-
course, the control group in Kempner’s day had a survival ance.27 In contrast to his staunch supporter, Eugene Stead,
expectancy estimated at 6 months. Kempner believed in max- he did not leave a legend or a legacy of followers inhabit-
imal therapy; “drag it out by the roots.” Did Kempner pres- ing chairmanships in academic medicine.28 As a matter of
ent his best data? We certainly hope so, exactly as clinician/ fact, mentorship does not seem to have been a strong point,
scientists today roll out their best Western blots in any paper although he was guided by several superb mentors. Not all
(who would do less?). Only 2 options exist, stated Gordon Duke house staff physicians remember Kempner with favor.
et al,19 who inspected the efficacy of parachute use in those When one of his rice diet patients had to be resuscitated
jumping from airplanes. They dared to raise the hypothesis after developing urosepsis and shock, Kempner threw a fit
that perhaps parachutes are worthless—“where are the neces- when the patient was given volume expansion with normal
sary randomized-controlled results?” Their first suggestion is saline (David G. Harrison, MD, personal communication,
that we accept under exceptional circumstances the notion June 2014). We have no data on Kempner’s grant support,
that common sense might be applied when considering the although his celebrity patients probably generated income
potential risks and benefits of interventions. The second crite- for Duke University Hospital.
rion is that we continue our quest for the holy grails of exclu-
sively evidence-based interventions and preclude parachute Perspectives
use outside the context of a properly conducted trial, fore- Clearly, Kempner was provocative, from his personality, his
going common sense. (You figure it out!) The dependency background, and his data. Current evidence-based require-
we have created in our population may make recruitment of ments are not fulfilled, but doubters could eschew para-
the unenlightened masses to such a trial difficult. If so, the chutes.19 Are more marginal dietary salt reductions helpful?
authors are assured that “those who advocate evidence-based A correspondence between Kempner and Volhard does not
medicine and criticize use of interventions that lack an evi- inspire confidence. We are looking for advances that are slow.
dence base will not hesitate to demonstrate their commitment So what caused Kempner to swim against the stream? The
by volunteering for a double blind, randomized, placebo-con- stream currently requires a highly confined method of thought
trolled, crossover trial.” for research support where the final idea must be supported
Kempner’s career was not beyond critique. Kempner before the end results are known. Finally, what was the driv-
received the 1975 (forerunner) Excellence in Hypertension ing force in the method of thought behind Walter Kempner
Research Award, along with Lewis Dahl and James O. that caused him to swim against the stream? There was an
Davis, although his anecdotal case reports20 cannot really unfulfilled idealism in his character, perhaps dating back to
compare with the output of these 2 excellent physiolo- mysticism and Stefan George. Possibly, a return to the roots
gists.21,22 Kempner never attended the Annual Council for is indicated. The ideas outlined by Firestein regarding how
High Blood Pressure meetings after 1975, in the authors’ ignorance drives science may help us here.29 Nonetheless,
memories. He never consulted with Homer Smith23 or Carl the missed opportunities and failure to capitalize on the data
Gottschalk,24 the latter a mere 15 miles away, about renal in an organized and collaborative fashion mark Kempner.
physiology. Had he done so, he might have pre-empted Stubbornness is both a helpful and a harmful attribute in sci-
Bricker’s trade-off hypothesis,25 predicted the intact nephron entific discovery.
Downloaded from http://hyper.ahajournals.org/ by guest on October 29, 2015
688  Hypertension  October 2014

Acknowledgment 13. Kempner W. Treatment of kidney disease and hypertensive vascular dis-
ease with the rice diet. N C Med J. 1944;5:125–133.
None of us worked with Walter Kemper personally, although we all
14. Kempner W. Treatment of kidney disease and hypertensive vascular dis-
suffered under tachycardia at Grand Rounds presentation to Eugene
ease with the rice diet II. N C Med J. 1944;5:272–274.
Stead.6 This brief commentary would not have been possible without
15. Kempner W. Compensation of renal metabolic dysfunction: Treatment of
access to Barbara Newborg’s delightful book on Walter Kempner and
kidney disease and hypertensive vascular disease with rice diet, III. Part 1.
the Rice Diet.4 Kempner’s articles have been republished, edited by N C Med J. 1945;6:61–87.
Newborg, in 2002.30 Since submission of this report, we are aware 16. Kempner W. Compensation of renal metabolic dysfunction: Treatment of
of an editorial that has been published on the activities of Walter kidney disease and hypertensive vascular disease with rice diet, III. Part 2.
Kempner, focused on obesity.31 N C Med J. 1945;6:117–161.
17. Kempner W. Some effects of the rice diet treatment of kidney disease and
Disclosures hypertension. Bull N Y Acad Med. 1946;22:358–370.
None. 18. Stead EA, Jr. Walter Kempner: a perspective. Arch Intern Med.
1974;133:756–757.
19. Smith GCS, Pell JP. Parachute use to prevent death and major trauma
References related to gravitational challenge: systematic review of randomised con-
1. Volhard F, Suter F. Nieren und Ableitende Harnwege. In: von Bergmann trolled trials. BMJ. 2003;327:1460–1461.
G, Staehelin R, eds. Handbuch der inneren Medizin. Vol. 6, Part I. Berlin, 20. Kempner W, Newborg BC, Peschel RL, Skyler JS. Treatment of massive
Germany: Springer; 1931. obesity with rice/reduction diet program. An analysis of 106 patients with
2. Lennert T, Luft FC. Kidneys on vacation: the notion of renal work and the intro- at least a 45-kg weight loss. Arch Intern Med. 1975;135:1575–1584.
duction of nonpharmacological therapies. Am J Kidney Dis. 1997;29:777–780. 21. Dahl LK, Heine M. Primary role of renal homografts in setting chronic
3. Kempner W. Treatment of heart and kidney disease and of hypertensive blood pressure levels in rats. Circ Res. 1975;36:692–696.
and arteriosclerotic vascular disease with the rice diet. Ann Intern Med.
22. Davis JO. The pathogenesis of chronic renovascular hypertension. Circ
1949;31:821–856, illust.
Res. 1977;40:439–444.
4. Newborg B. Walter Kempner and the Rice Diet. Durham, NC: Carolina
23. Smith HW. The Kidney. New York, NY: Oxford University Press, Inc;
Academic Press; 2011.
1951.
5. Stead EA, Jr. Dr. Walter Kempner and the Rice Diet program: another
24. Gottschalk CW. History of the urinary concentrating mechanism. Kidney
reason why Durham is the City of Medicine. N C Med J. 1997;58:395.
Int. 1987;31:507–511.
6. Moss AJ, Wynar B. Tachycardia in house officers presenting cases at
grand rounds. Ann Intern Med. 1970;72:255–256. 25. Bricker NS. On the pathogenesis of the uremic state. An exposition of the
7. Fritz S. The Politics of Cultural Despair: A Study on the Rise of the Germanic “trade-off hypothesis.” N Engl J Med. 1972;286:1093–1099.
Ideology. Berkeley, CA: University of California Press; 1961:296. 26. Slatopolsky E. The intact nephron hypothesis: the concept and its implica-
8. Kempner W. Chemical nature of the oxygen-transferring ferment of respi- tions for phosphate management in CKD-related mineral and bone disor-
ration in plants. Plant Physiol. 1936;11:605–613. der. Kidney Int Suppl. 2011;121:S3–S8.
9. Kempner W. The metabolism of human erythroblasts. J Clin Invest. 27. Titze J, Dahlmann A, Lerchl K, Kopp C, Rakova N, Schröder A, Luft FC.
1936;15:679–683. Spooky sodium balance. Kidney Int. 2014;85:759–767.
10. Kempner W. The nature of leukemic blood cells as determined by their 28. Stead EA. Wisdom from a medical elder. CMAJ. 2004;171:1465–1466.
metabolism. J Clin Invest. 1939;18:291–300. 29. Firestein S. Ignorance, How it Drives Science. New York: Columbia
11. Kempner W, Schlayer C. Effect of CO2 on the growth rate of the pneumo- University Press; 2012.
coccus. J Bacteriol. 1942;43:387–396. 30. Newborg B (Ed). Scientific Publications by Walter Kempner, MD. Vol I
12. Peschel E, Black-Schaffer B, Schlayer C. Potassium deficiency as cause and Vol II. Durham, NC: Gravity Press; 2002.
of the so-called rheumatic heart lesions of the adaptation syndrome. 31. Rössner S. “Just do it!” Walter Kempner (1903–1997). Obes Rev.
Endocrinology. 1951;48:399–407. 2010;7:550–551.

Downloaded from http://hyper.ahajournals.org/ by guest on October 29, 2015

 Who and What Drove Walter Kempner?: The Rice Diet Revisited
Philip Klemmer, Clarence E. Grim and Friedrich C. Luft

Hypertension. 2014;64:684-688; originally published online July 7, 2014;

doi: 10.1161/HYPERTENSIONAHA.114.03946
Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2014 American Heart Association, Inc. All rights reserved.
Print ISSN: 0194-911X. Online ISSN: 1524-4563

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://hyper.ahajournals.org/content/64/4/684

Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located,
click Request Permissions in the middle column of the Web page under Services. Further information about
this process is available in the Permissions and Rights Question and Answer document.

Reprints: Information about reprints can be found online at:

http://www.lww.com/reprints

Subscriptions: Information about subscribing to Hypertension is online at:

http://hyper.ahajournals.org//subscriptions/

Downloaded from http://hyper.ahajournals.org/ by guest on October 29, 2015

View publication stats