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Eyal O, Ben-Dov IZ. The Role of Blood Pressure Load in Ambulatory Blood Pressure Monitoring in Adults: A Literature Review of Current Evidence. Diagnostics (Basel) 2023; 13:2485. [PMID: 37568848 PMCID: PMC10417809 DOI: 10.3390/diagnostics13152485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The blood pressure load (BPL) is commonly defined as the percentage of readings in a 24-h ambulatory blood pressure monitoring (ABPM) study above a certain threshold, usually the upper normal limit. While it has been studied since the 1990s, the benefits of using this index have not been clearly demonstrated in adults. We present the first review on the associations of BPL with target organ damage (TOD) and clinical outcomes in adults, the major determinants for its role and utility in blood pressure measurement. We emphasize studies which evaluated whether BPL has added benefit to the average blood pressure indices on ABPM in predicting adverse outcomes. METHODS PubMed search for all English language papers mentioning ABPM and BPL. RESULTS While multiple studies assessed this question, the cumulative sample size is small. Whereas the associations of BPL with various TODs are evident, the available literature fails to demonstrate a clear and consistent added value for the BPL over the average blood pressure indices. CONCLUSIONS There is a need for prospective studies evaluating the role of BPL in blood pressure measurement. The current literature does not provide sound support for the use of BPL in clinical decisions.
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Affiliation(s)
- Ophir Eyal
- Department of Nephrology and Hypertension, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel;
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2
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Panuccio V, Provenzano PF, Tripepi R, Versace MC, Parlongo G, Politi E, Vilasi A, Mezzatesta S, Abelardo D, Tripepi GL, Torino C. Home Pulse Pressure Predicts Death and Cardiovascular Events in Peritoneal Dialysis Patients. J Clin Med 2023; 12:3904. [PMID: 37373599 DOI: 10.3390/jcm12123904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/29/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Increased arterial hypertension represents a prevalent condition in peritoneal dialysis patients that is often related to volume expansion. Pulse pressure is a robust predictor of mortality in dialysis patients, but its association with mortality is unknown in peritoneal patients. We investigated the relationship between home pulse pressure and survival in 140 PD patients. During a mean follow-up of 35 months, 62 patients died, and 66 experienced the combined event death/CV events. In a crude COX regression analysis, a five-unit increase in HPP was associated with a 17% increase in the hazard ratio of mortality (HR: 1.17, 95% CI 1.08-1.26 p < 0.001). This result was confirmed in a multiple Cox model adjusted for age, gender, diabetes, systolic arterial pressure, and dialysis adequacy (HR: 1.31, 95% CI 1.12-1.52, p = 0.001). Similar results were obtained considering the combined event death-CV events as an outcome. Home pulse pressure represents, in part, arterial stiffness, and it is strongly related to all-cause mortality in peritoneal patients. In these high cardiovascular risk populations, it is important to maintain optimal blood pressure control, but it is fundamental to consider all the other cardiovascular risk indicators, such as pulse pressure. Home pulse pressure measurement is easy and feasible and can add important information for the identification and management of high-risk patients.
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Affiliation(s)
- Vincenzo Panuccio
- Nephology, Dialysis and Transplantation Unit-GOM "Bianchi-Melacrino-Morelli", Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Pasquale Fabio Provenzano
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Rocco Tripepi
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Maria Carmela Versace
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Giovanna Parlongo
- Nephology, Dialysis and Transplantation Unit-GOM "Bianchi-Melacrino-Morelli", Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Emma Politi
- Nephology, Dialysis and Transplantation Unit-GOM "Bianchi-Melacrino-Morelli", Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Antonio Vilasi
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Sabrina Mezzatesta
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Domenico Abelardo
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Giovanni Luigi Tripepi
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
| | - Claudia Torino
- National Research Council-Institute of Clinical Physiology, Via Vallone Petrara SNC, 89124 Reggio Calabria, Italy
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3
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Luyan G, Haixia Z, Sheng F, Gang S, Jing Z, Ying L, Linsen J, Kai S, Zhi W, Huaying S. Regression of Left Ventricular Hypertrophy in Patients Combined with Peritoneal Dialysis and Hemodialysis. Int J Clin Pract 2022; 2022:2652380. [PMID: 36518909 PMCID: PMC9719434 DOI: 10.1155/2022/2652380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022] Open
Abstract
METHODS This retrospective study enrolled 58 patients at The Second Affiliated Hospital of Soochow University who switched from PD to PHD. Clinical data and echocardiographic examination results were collected. Data from the two groups with a normal distribution were compared with the paired t-test. A pvalue <0.05 (two-tailed) was considered statistically significant. RESULTS A total of 58 subjects were enrolled, including 46 males and 12 females, with a median age of 50.2 ± 11.1 (47-68) years. The mean duration of peritoneal dialysis was 67.2 ± 33.6 months. Before and after PHD, the ultrafiltration volume (p = 0.021) and hemoglobin (p = 0.001) were increased, while SBP (p = 0.002), DBP (p = 0.002), phosphorus (p < 0.001), and ESA dosage (p < 0.001) were decreased. Before and after combined dialysis (PHD), the incidence of LVH was 76.4% and 61.8%, respectively (p = 0.013), and LVMI decreased from 173.8 ± 86.2 g/m2 to 160.6 ± 78.5 g/m2 (p < 0.001). CONCLUSION Compared with PD alone, the combination of PD and HD resulted in regression of LVH and reduced LVMI.
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Affiliation(s)
- Gao Luyan
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhang Haixia
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Sheng
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Sun Gang
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhu Jing
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Lu Ying
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiang Linsen
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Song Kai
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wang Zhi
- The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shen Huaying
- The Second Affiliated Hospital of Soochow University, Suzhou, China
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Lenihan CR, Liu S, Airy M, Walther C, Montez-Rath ME, Winkelmayer WC. The Association of Pre-Kidney Transplant Dialysis Modality with de novo Posttransplant Heart Failure. Cardiorenal Med 2021; 11:209-217. [PMID: 34515084 DOI: 10.1159/000518535] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/25/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Heart failure (HF) after kidney transplantation is a significant but understudied problem. Pretransplant dialysis modality could influence incident HF risk through differing cardiac stressors. However, whether pretransplant dialysis modality is associated with the development of posttransplant HF is unknown. METHODS We used the US Renal Data System to assemble a cohort of 27,701 patients who underwent their first kidney transplant in the USA between the years 2005 and 2012 and who had Medicare fee-for-service coverage for >6 months preceding their transplant date. Patients with any HF diagnosis prior to transplant were excluded. Detailed baseline patient characteristics and comorbidities were abstracted. The outcome of interest was de novo posttransplant HF. Pretransplant dialysis modality was defined as the dialysis modality used at the time of transplant. We conducted time-to-event analyses using Cox regression. Death was treated as a competing risk in the study's primary analysis. Graft failure was included as a time-varying covariate. RESULTS Among eligible patients, 81% were treated with hemodialysis prior to transplant, and hemodialysis patients were more likely to be male, had a shorter dialysis vintage, and had more diabetes and vascular disease diagnoses. When adjusted for all available demographic and clinical data, pretransplant treatment with hemodialysis (vs. peritoneal dialysis) was associated with a 19% increased risk in de novo posttransplant HF, with sub-distribution HR 1.19 (95% CI: 1.09-1.29). CONCLUSIONS Our results suggest that choice of pretransplant dialysis modality may impact the development of posttransplant HF.
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Affiliation(s)
- Colin R Lenihan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Medha Airy
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Carl Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
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Roumeliotis A, Roumeliotis S, Leivaditis K, Salmas M, Eleftheriadis T, Liakopoulos V. APD or CAPD: one glove does not fit all. Int Urol Nephrol 2020; 53:1149-1160. [PMID: 33051854 PMCID: PMC7553382 DOI: 10.1007/s11255-020-02678-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 10/03/2020] [Indexed: 12/16/2022]
Abstract
The use of Automated Peritoneal Dialysis (APD) in its various forms has increased over the past few years mainly in developed countries. This could be attributed to improved cycler design, apparent lifestyle benefits and the ability to achieve adequacy and ultrafiltration targets. However, the dilemma of choosing the superior modality between APD and Continuous Ambulatory Peritoneal Dialysis (CAPD) has not yet been resolved. When it comes to fast transporters and assisted PD, APD is certainly considered the most suitable Peritoneal Dialysis (PD) modality. Improved patients’ compliance, lower intraperitoneal pressure and possibly lower incidence of peritonitis have been also associated with APD. However, concerns regarding increased cost, a more rapid decline in residual renal function, inadequate sodium removal and disturbed sleep are APD’s setbacks. Besides APD superiority over CAPD in fast transporters, the other medical advantages of APD still remain controversial. In any case, APD should be readily available for all patients starting PD and the most important indication for its implementation remains patient’s choice.
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Affiliation(s)
- Athanasios Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, 1, St. Kyriakidi Street, 54636, Thessaloníki, Greece
| | - Stefanos Roumeliotis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, 1, St. Kyriakidi Street, 54636, Thessaloníki, Greece
| | - Konstantinos Leivaditis
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, 1, St. Kyriakidi Street, 54636, Thessaloníki, Greece
| | - Marios Salmas
- Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Vassilios Liakopoulos
- Division of Nephrology and Hypertension, 1st Department of Internal Medicine, AHEPA University Hospital, School of Medicine, Aristotle University of Thessaloniki, 1, St. Kyriakidi Street, 54636, Thessaloníki, Greece.
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Doulton TWR, Swift PA, Murtaza A, Dasgupta I. Uncertainties in BP management in dialysis patients. Semin Dial 2020; 33:223-235. [PMID: 32285984 DOI: 10.1111/sdi.12880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 12/21/2022]
Abstract
Hypertension in dialysis patients is extremely common. In this article, we review the current evidence for blood pressure (BP) goals in hemodialysis patients, and consider the effectiveness of interventions by which BP may be lowered, including manipulation of dietary and dialysate sodium; optimization of extracellular water; prolongation of dialysis time; and antihypertensive medication. Although two meta-analyses suggest lowering BP using antihypertensive drugs might be beneficial in reducing cardiovascular events and mortality, there are insufficient rigorously designed trials in hypertensive hemodialysis populations to determine preferred antihypertensive drug classes. We suggest aiming for predialysis systolic BP between 130 and 159 mm Hg, while at the same time acknowledge the significant limitations of the data upon which it is based. We conclude by summarizing current knowledge as regards management of hypertension in the peritoneal dialysis population and make recommendations for future research in this field.
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Affiliation(s)
- Timothy W R Doulton
- Department of Renal Medicine, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
| | - Pauline A Swift
- Department of Nephrology, Epsom and St Helier University Hospitals NHS Trust, Carshalton, Surrey, UK
| | - Asam Murtaza
- Renal Unit, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Indranil Dasgupta
- Renal Unit, University Hospitals Birmingham NHS Trust, Birmingham, UK.,Warwick Medical School, University of Warwick, Warwick, UK
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Rodríguez–Carmona A, Fontán MP. Sodium Removal in Patients Undergoing CAPD and Automated Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080202200610] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives To compare sodium removal in continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) patients, and to identify the main factors that modify Na removal in clinical practice in these patients. Design Study in three steps. Cross-sectional observational (Study A), and longitudinal interventional (Studies B and C). Patients and Methods First (Study A) we carried out a cross-sectional survey of Na removal in 63 patients on CAPD and 78 patients on APD. Second (Study B), we studied Na removal in 32 patients before and after changing from CAPD to APD therapy. Finally (Study C), we analyzed the impact on Na removal of introducing icodextrin for the long dwell in 16 patients undergoing CAPD or APD. Results In Study A, total Na removal averaged 210 mmol/day for CAPD patients and 91 mmol/day for APD patients ( p < 0.001); Na removal was < 100 mmol/day in 7.1% of CAPD patients and 56.4% of APD patients. Multivariate analysis identified ultrafiltration [B = 125 mmol/day, 95% confidence interval (CI) 110, 140], CAPD therapy (B = 60 mmol/day, 95%CI 37, 83), and residual diuresis (B = 51 mmol/L, 95%CI 34, 69) as independent predictors of Na removal (adjusted r2 = 0.76). For APD patients, longer nocturnal dwell times and performing a supplementary diurnal exchange were also independently associated with higher Na removal rates. In Study B, Na removal decreased from 192 to 92 mmol/day (median) after the change to APD ( p = 0.02). In Study C, peritoneal Na removal increased from 98 to 148 mmol/day (median) ( p = 0.04) after introducing icodextrin. Conclusions Standard APD schedules are frequently associated with poor Na removal rates. For any degree of ultrafiltration, Na removal is better in CAPD than in APD. Icodextrin, supplementary diurnal exchanges, and longer nocturnal dwell times improve Na removal in APD. Sodium removal can be estimated from ultrafiltration in patients on CAPD, but must be specifically monitored in patients on APD.
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Konings CJ, Kooman JP, van der Sande FM, Leunissen KM. Fluid Status in Peritoneal Dialysis: What's New? Perit Dial Int 2020. [DOI: 10.1177/089686080302300312] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Jeroen P. Kooman
- Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
| | - Frank M. van der Sande
- Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
| | - Karel M.L. Leunissen
- Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
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9
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Tonbul Z, Altintepe L, Sözlü Ç, Yeksan M, Yildiz A, Türk S. The Association of Peritoneal Transport Properties with 24-Hour Blood Pressure Levels in Capd Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080302300106] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
← Objectives We aimed to investigate the effects of peritoneal transport characteristics on blood pressure (BP) parameters, measured by 24-hour ambulatory blood pressure monitoring (ABPM), and on the development of left ventricular hypertrophy (LVH) in continuous ambulatory peritoneal dialysis (CAPD) patients. ← Design Cross-sectional and prospective design. ← Setting Tertiary-care center. ← Patients 25 CAPD patients (11 male, 14 female; mean age 47 ± 14 years) were included. Mean time on CAPD was 22.9 ± 18 months and all patients had been dialyzed for more than 6 months. The patients were divided into high, high-average, low-average, and low transport groups according to peritoneal equilibration test results. ← Main Outcome Measures Daytime and nighttime systolic and diastolic BP and left ventricular mass index among the different peritoneal transport groups; changes in BP parameters before and after increase in ultrafiltration. ← Results On 24-hour ABPM records, 13 patients (52%) were found to be hypertensive. Both mean systolic and diastolic BP were significantly increased in high-transporter groups compared to low transporters in both daytime and nighttime BP parameters. Left ventricular mass index was higher in high transporters compared to low transporters, without reaching statistical significance: 160 ± 23 vs 119 ± 41 g/m2, p > 0.05. Following increase in ultrafiltration, mean systolic (145 ± 13 vs 128 ± 5 mmHg, p < 0.001) and diastolic (96 ± 10 vs 81 ± 3 mm Hg, p < 0.001) BP decreased, and BP levels returned to normotensive levels in 6 (46%) of the 13 hypertensive patients, requiring discontinuation of antihypertensive drugs. ← Conclusion Improvement in volume status resulted in a decrease in both daytime and nighttime BP. Differences in peritoneal transport properties were associated with the development of hypertension and LVH.
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Affiliation(s)
- Zeki Tonbul
- Division of Nephrology, Istanbul, Turkey
- Department of Internal Medicine, Selcuk University Medical School, Konya, Istanbul, Turkey
| | - Lutfullah Altintepe
- Division of Nephrology, Istanbul, Turkey
- Department of Internal Medicine, Selcuk University Medical School, Konya, Istanbul, Turkey
| | - Çetin Sözlü
- Department of Internal Medicine, Selcuk University Medical School, Konya, Istanbul, Turkey
| | - Mehdi Yeksan
- Division of Nephrology, Istanbul, Turkey
- Department of Internal Medicine, Selcuk University Medical School, Konya, Istanbul, Turkey
| | - Alaattin Yildiz
- Division of Nephrology, Department of Internal Medicine, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Süleyman Türk
- Division of Nephrology, Istanbul, Turkey
- Department of Internal Medicine, Selcuk University Medical School, Konya, Istanbul, Turkey
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Vaios V, Georgianos PI, Liakopoulos V, Agarwal R. Assessment and Management of Hypertension among Patients on Peritoneal Dialysis. Clin J Am Soc Nephrol 2019; 14:297-305. [PMID: 30341090 PMCID: PMC6390915 DOI: 10.2215/cjn.07480618] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Approximately 7%-10% of patients with ESKD worldwide undergo peritoneal dialysis (PD) as kidney replacement therapy. The continuous nature of this dialytic modality and the absence of acute shifts in pressure and volume parameters is an important differentiation between PD and in-center hemodialysis. However, the burden of hypertension and prognostic association of BP with mortality follow comparable patterns in both modalities. Although management of hypertension uses similar therapeutic principles, long-term preservation of residual diuresis and longevity of peritoneal membrane function require particular attention in the prescription of the appropriate dialysis regimen among those on PD. Dietary sodium restriction, appropriate use of icodextrin, and limited exposure of peritoneal membrane to bioincompatible solutions, as well as adaptation of the PD regimen to the peritoneal transport characteristics, are first-line therapeutic strategies to achieve adequate volume control with a potential long-term benefit on technique survival. Antihypertensive drug therapy is a second-line therapeutic approach, used when BP remains unresponsive to the above volume management strategies. In this article, we review the available evidence on epidemiology, diagnosis, and treatment of hypertension among patients on PD and discuss similarities and differences between PD and in-center hemodialysis. We conclude with a call for randomized trials aiming to elucidate several areas of uncertainty in management of hypertension in the PD population.
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Affiliation(s)
- Vasilios Vaios
- Peritoneal Dialysis Unit, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | - Panagiotis I. Georgianos
- Peritoneal Dialysis Unit, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | - Vassilios Liakopoulos
- Peritoneal Dialysis Unit, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; and
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
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Chia YC, Buranakitjaroen P, Chen CH, Divinagracia R, Hoshide S, Park S, Shin J, Siddique S, Sison J, Soenarta AA, Sogunuru GP, Tay JC, Turana Y, Wang JG, Wong L, Zhang Y, Kario K. Current status of home blood pressure monitoring in Asia: Statement from the HOPE Asia Network. J Clin Hypertens (Greenwich) 2017; 19:1192-1201. [PMID: 28815840 DOI: 10.1111/jch.13058] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 05/25/2017] [Accepted: 05/29/2017] [Indexed: 12/15/2022]
Abstract
Hypertension represents a major burden in Asia, with a high prevalence rate but poor level of awareness and control reported in many countries in the region. Home blood pressure monitoring has been validated as an accurate and reliable measure of blood pressure that can help guide hypertension treatment as well as identify masked and white-coat hypertension. Despite its benefits, there has been limited research into home blood pressure monitoring in Asia. The authors reviewed the current evidence on home blood pressure monitoring in Asia, including but not limited to published literature, data presented at congresses, and national hypertension management guidelines to determine the current utilization of home blood pressure monitoring in clinical practice in the region. Public policies to enable greater access to home blood pressure monitoring and its use in clinical care would add considerably to improving hypertension outcomes in Asia.
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Affiliation(s)
- Yook-Chin Chia
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Sunway lnstitute for Healthcare Development, Sunway University, Selangor Darul Ehsan, Malaysia
| | - Peera Buranakitjaroen
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chen-Huan Chen
- Department of Medicine, Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Romeo Divinagracia
- University of the East Ramon Magsaysay Memorial Medical Center Inc, Quezon City, Philippines
| | - Satoshi Hoshide
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Sungha Park
- Division of Cardiology, Cardiovascular Hospital, Yonsei Health System, Seoul, Korea
| | - Jinho Shin
- Faculty of Cardiology Service, Hanyang University Medical Center, Seongdong, Seoul, Korea
| | | | - Jorge Sison
- Department of Medicine, Medical Center Manila, Ermita, Manila, Philippines
| | - Arieska Ann Soenarta
- Department Cardiology and Vascular Medicine, Faculty of Medicine, Harapan Kita, University of Indonesia-National Cardiovascular Center, Jakarta, Indonesia
| | - Guru Prasad Sogunuru
- Apollo Hospitals, Chennai, India.,College of Medical Sciences, Kathmandu University, Bharatpur, Nepal
| | - Jam Chin Tay
- Department of General Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yuda Turana
- Department of Neurology, Faculty of Medicine, Atma Jaya Catholic University of Indonesia, North Jakarta, Jakarta, Indonesia
| | - Ji-Guang Wang
- Department of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Shanghai Key Laboratory of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lawrence Wong
- Department of Medicine & Therapeutics, Division of Neurology, Chinese University of Hong Kong, Hong Kong
| | - Yuqing Zhang
- Divisions of Hypertension and Heart Failure, Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
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12
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Ataş N, Erten Y, Okyay GU, Inal S, Topal S, Öneç K, Akyel A, Çelik B, Tavil Y, Bali M, Arınsoy T. Left ventricular hypertrophy and blood pressure control in automated and continuous ambulatory peritoneal dialysis patients. Ther Apher Dial 2015; 18:297-304. [PMID: 24965296 DOI: 10.1111/1744-9987.12104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hypertension, non-dipper blood pressure (BP) pattern and decrease in daily urine output have been associated with left ventricular hypertrophy (LVH) in peritoneal dialysis (PD) patients. However, there is lack of data regarding the impact of different PD regimens on these factors. We aimed to investigate the impact of circadian rhythm of BP on LVH in end-stage renal disease patients using automated peritoneal dialysis (APD) or continuous ambulatory peritoneal dialysis (CAPD) modalities. Twenty APD (7 men, 13 women) and 28 CAPD (16 men, 12 women) patients were included into the study. 24-h ambulatory blood pressure monitoring (ABPM) and transthoracic echocardiography besides routine blood examinations were performed. Two groups were compared with each other for ABPM measurements, BP loads, dipping patterns, left ventricular mass index (LVMI) and daily urine output. Mean systolic and diastolic BP measurements, BP loads, LVMI, residual renal function (RRF) and percentage of non-dippers were found to be similar for the two groups. There were positive correlations of LVMI with BP measurements and BP loads. LVMI was found to be significantly higher in diastolic non-dippers compared to dippers (140.4 ± 35.3 vs 114.5 ± 29.7, respectively, P = 0.02). RRF and BP were found to be independent predictors of LVMI. Non-dipping BP pattern was a frequent finding among all PD patients without an inter-group difference. Additionally, higher BP measurements, decrease in daily urine output and non-dipper diastolic BP pattern were associated with LVMI. In order to avoid LVH, besides correction of anemia and volume control, circadian BP variability and diastolic dipping should also be taken into consideration in PD patients.
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Affiliation(s)
- Nuh Ataş
- Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
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Agarwal R, Flynn J, Pogue V, Rahman M, Reisin E, Weir MR. Assessment and management of hypertension in patients on dialysis. J Am Soc Nephrol 2014; 25:1630-46. [PMID: 24700870 PMCID: PMC4116052 DOI: 10.1681/asn.2013060601] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana;
| | - Joseph Flynn
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Velvie Pogue
- formerly Division of Nephrology, Harlem Hospital, Columbia University College of Physicians & Surgeons, New York, New York
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Efrain Reisin
- Division of Nephrology and Hypertension, Louisiana State University Health Science Center, New Orleans, Louisiana; and
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Is blood pressure load associated, independently of blood pressure level, with target organ damage? J Hypertens 2014; 31:1812-8. [PMID: 23743810 DOI: 10.1097/hjh.0b013e3283624f9b] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Blood pressure (BP) load, defined as the percentage of abnormally elevated BP readings, is usually provided on the report of ambulatory BP monitoring. However, the usefulness of BP load is still uncertain. In the present study, we examined whether BP load would be associated, independently of BP level, with target organ damage. METHODS We recruited 869 individuals (430 men, mean age 51 years) who were referred for 24-h ambulatory BP monitoring and were off antihypertensive medication for at least 2 weeks. BP load was defined as the percentage of daytime and nighttime SBP/DBP readings at least 135/85 and at least 120/70 mmHg, respectively. Brachial-ankle pulse wave velocity (baPWV) and carotid-femoral pulse wave velocity (cfPWV), left ventricular mass index (LVMI) and urinary albumin-to-creatinine ratio (ACR) were determined as measures of target organ damage. RESULTS SBP and DBP load had a skewed distribution (P<0.001). In multivariate-adjusted categorical analyses, baPWV (13.8, 14.6 and 15.6 m/s), cfPWV (7.4, 7.7 and 8.4 m/s), LVMI (90.1, 94.8 and 100.7 g/m) and ACR (0.47, 0.58 and 0.77 mg/mmol) all increased from tertiles 1-3 of SBP load (P<0.001). However, these differences became nonsignificant (P ≥ 0.16) after additionally adjusted for 24-h SBP level. In a continuous analysis in individuals with a BP load greater than zero (n=838), adding the logarithmically transformed SBP load did not improve the fit of models relating measures of target organ damage to SBP level (P ≥ 0.14), except for cfPWV (P=0.01) that was however negatively associated with BP load. Analyses on DBP load produced similar results. CONCLUSION BP load was associated with target organ damage, but not independently of BP level.
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Cohen DL, Huan Y, Townsend RR. Ambulatory blood pressure in chronic kidney disease. Curr Hypertens Rep 2013; 63:835-42. [PMID: 23595357 DOI: 10.1053/j.ajkd.2013.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/11/2013] [Indexed: 01/13/2023]
Abstract
Chronic kidney disease (CKD) affects approximately 20 million adults in the United States. Patients with CKD have an increased risk of cardiovascular (CV) disease. Ambulatory blood pressure monitoring (ABPM) provides superior BP measurements when compared to office BP measurements in normotensive, hypertensive and CKD patients. ABPM measurements are often abnormal in CKD, with CKD patients frequently showing an altered circadian rhythm with an increased rate of non-dipping and reverse dipping. The prevalence of non-dippers and reverse-dippers increases progressively as stage of CKD progresses. ABPM has been shown to be a better tool for predicting CV risk, CKD progression, end stage renal disease (ESRD) or death than office-based pressures. ABPM is also additive and adds prognostic value for predicting CKD and CV outcomes when added to estimated glomerular filtration rate (eGFR). Although ABPM is time consuming, it is worth considering, as the data demonstrates that information from ABPM can potentially impact future CV and renal outcomes in patients with CKD.
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Affiliation(s)
- Debbie L Cohen
- Perelman School of Medicine at the University of Pennsylvania, Renal, Electrolyte and Hypertension Division, 1 Founders Building 3400 Spruce Street, Philadelphia, PA 19104, USA.
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O'Shaughnessy MM, Durcan M, Kinsella SM, Griffin MD, Reddan DN, Lappin DW. Blood pressure measurement in peritoneal dialysis: which method is best? Perit Dial Int 2013; 33:544-51. [PMID: 23547279 DOI: 10.3747/pdi.2012.00027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The optimal approach to monitoring blood pressure (BP) in the peritoneal dialysis (PD) population is unclear. Ambulatory BP monitoring reliably predicts prognosis, but can be inconvenient. The accuracy of home BP monitoring in this population is unproven. The automated BpTRU device (BpTRU Medical Devices, Coquitlam, BC, Canada), which provides an average of up to 6 successive in-office BP measurements, has not been studied in this patient group. METHODS We studied 17 patients (average age: 54 ± 12 years; 12 men, 5 women; 94% on automated PD) attending a single center. All patients underwent office, home, BpTRU, and ambulatory BP measurement. The reference standard for analysis was daytime ambulatory BP. Correlation between the referent method and each comparator method was determined (Pearson correlation coefficient), and Bland-Altman scatter plots depicting the differences in the BP measurements were constructed. RESULTS Mean office BP (126.4 ± 16.9/78.8 ± 11.6 mmHg) and BpTRU BP (123.8 ± 13.7/80.7 ± 11.1 mmHg) closely approximated mean daytime ambulatory BP (129.3 ± 14.8/78.2 ± 7.9 mmHg). Mean home BP (143.8 ± 15.0/89.9 ± 28.1 mmHg) significantly overestimated mean daytime systolic BP by 14.2 mmHg (95% confidence interval: 4.3 mmHg to 24.1 mmHg; p = 0.008). Bland-Altman plots demonstrated poorest agreement between home BP and daytime ambulatory BP. No patient had "white-coat hypertension," and only 1 patient had false-resistant hypertension. Most patients showed abnormal nocturnal dipping patterns (non-dipping: n = 11; reverse-dipping: n = 5; normal dipping: n = 1). CONCLUSIONS We report a novel finding that BP measurement using the BpTRU device is more accurate than home BP measurement in a PD population. Potential explanations for this observation include poor home BP measurement technique, use of poorly validated home BP measurement devices, or a reduced prevalence of white-coat effect among PD patients. Our study also confirms that, in the PD population, BP measurements vary considerably with patient location, time of day, and measurement technique.
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Affiliation(s)
- Michelle M O'Shaughnessy
- Nephrology Services,1 Galway University Hospitals, and College of Medicine Nursing and Health Sciences,2 National University of Ireland, Galway, Ireland
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Terawaki H, Shoda T, Ogura M, Mitome J, Yamamoto H, Yokoyama K, Hosoya T. Morning Hypertension Determined by Self-Measurement at Home Predicts Left Ventricular Hypertrophy in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis. Ther Apher Dial 2012; 16:260-6. [DOI: 10.1111/j.1744-9987.2012.01059.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Kanbay M, Turkmen K, Ecder T, Covic A. Ambulatory blood pressure monitoring: from old concepts to novel insights. Int Urol Nephrol 2011; 44:173-82. [DOI: 10.1007/s11255-011-0027-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 06/22/2011] [Indexed: 11/29/2022]
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Onofriescu M, Mardare NG, Segall L, Voroneanu L, Cuşai C, Hogaş S, Ardeleanu Ş, Nistor I, Prisadă OV, Sascău R, Covic A. Randomized trial of bioelectrical impedance analysis versus clinical criteria for guiding ultrafiltration in hemodialysis patients: effects on blood pressure, hydration status, and arterial stiffness. Int Urol Nephrol 2011; 44:583-91. [DOI: 10.1007/s11255-011-0022-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 06/10/2011] [Indexed: 01/10/2023]
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LIN JJ, MITSNEFES MM, SMOYER WE, VALENTINI RP. Antihypertensive prescription in pediatric dialysis: A practitioner survey by the Midwest Pediatric Nephrology Consortium study. Hemodial Int 2009; 13:307-15. [DOI: 10.1111/j.1542-4758.2009.00392.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cheng LT, Gao YL, Qin C, Tian JP, Gu Y, Bi SH, Tang W, Wang T. Volume Overhydration is Related to Endothelial Dysfunction in Continuous Ambulatory Peritoneal Dialysis Patients. Perit Dial Int 2008. [DOI: 10.1177/089686080802800415] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective In dialysis patients, volume overhydration is common and is related to increased risk of cardiovascular morbidity and mortality. However, it remains unclear whether volume overload imposes those detrimental effects through endothelial dysfunction. Methods In this cross-sectional study, 81 stable patients on continuous ambulatory peritoneal dialysis in a single center were recruited. Volume status was evaluated by extracellular water, assessed by bioimpedance analysis, and normalized to individual height (nECW). Endothelial function was estimated by endothelial-dependent flow-mediated dilatation (FMD) of the brachial artery and expressed as percentage change relative to baseline diameter. Results There were 37 male and 44 female patients (mean age 61 ± 12 years, dialysis vintage 20 ± 23 months). FMD in female patients was significantly higher than that in male patients (9.17% ± 6.23% vs 6.31% ± 5.01%, p < 0.05). FMD was negatively correlated with weight ( r = -0.308, p < 0.01), body mass index ( r = -0.242, p < 0.05), systolic blood pressure ( r = -0.228, p < 0.05), ECW ( r = -0.404, p < 0.001), and nECW ( r = -0.418, p < 0.001). No correlation was found between FMD and other variables. In multiple stepwise regression analysis, calcium x phosphate product (² = 0.422, p < 0.001), nECW (² = -0.343, p < 0.01), and dialysis vintage (² = -0.237, p < 0.05) were independent determinants of FMD (adjusted R2 = 0.327 for this model). Conclusion There was independent correlation between index of volume status and FMD, and higher nECW was related to worse endothelial function. The results of this study may help us understand the underlying mechanism of volume overhydration leading to increased cardiovascular morbidity and mortality in dialysis patients.
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Affiliation(s)
- Li-Tao Cheng
- Division of Nephrology, Peking University Third Hospital, Beijing
| | - Yan-Li Gao
- Division of Nephrology, Peking University Third Hospital, Beijing
- Division of Cardiology, The Second Clinical College of Guangzhou University of Chinese Traditional Medicine, Guangzhou
| | - Chao Qin
- Division of Nephrology, Peking University Third Hospital, Beijing
- Division of Nephrology, Qilu Hospital of Shandong University, Jinan
| | - Jun-Ping Tian
- Division of Nephrology, Peking University Third Hospital, Beijing
- Division of Cardiology, Beijing Tiantan Hospital, Capital University of Medical Sciences, Beijing, China
| | - Yue Gu
- Division of Nephrology, Peking University Third Hospital, Beijing
| | - Shu-Hong Bi
- Division of Nephrology, Peking University Third Hospital, Beijing
| | - Wen Tang
- Division of Nephrology, Peking University Third Hospital, Beijing
| | - Tao Wang
- Division of Nephrology, Peking University Third Hospital, Beijing
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Goldfarb-Rumyantzev AS, Baird BC, Leypoldt JK, Cheung AK. The association between BP and mortality in patients on chronic peritoneal dialysis. Nephrol Dial Transplant 2005; 20:1693-701. [PMID: 15899939 DOI: 10.1093/ndt/gfh856] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The relationship between blood pressure (BP) and mortality in haemodialysis patients is unconventional. It is not clear if this is the consequence of uraemia or related to the dialysis type. The goal of this project was to identify the relationship between BP and mortality in patients on chronic peritoneal dialysis (PD). METHODS Patients on PD (n = 1053) from the USRDS prospective DMMS Wave 2 study were analysed. Primary outcomes were all-cause and cardiovascular mortality and duration of hospitalization. RESULTS Low systolic BP categories, <100 mmHg [hazard ratio (HR), 2.71, P<0.001; and HR 3.83, P<0.001, respectively] and 101-110 mmHg (HR 1.85, P<0.05; and HR 2.92, P<0.005, respectively), but not high systolic BP, increased the risk of all-cause and cardiovascular mortality, with systolic BP 111-120 mmHg as the reference. Pulse BP, but not diastolic BP, followed a similar trend. In subgroup analysis, this association was demonstrated only in patients with a history of heart failure, in patients with diabetes and in those treated with antihypertensive medications. CONCLUSION Systolic BP <111 mmHg in PD patients is associated with higher mortality risk, while systolic BP >120 mmHg is associated with fewer hospital days. Aggressive treatment of hypertension in the PD population should be cautioned.
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Affiliation(s)
- Alexander S Goldfarb-Rumyantzev
- Division of Nephrology and Hypertension, University of Utah School of Medicine, 85 North Medical Drive, East Rm. 201, Salt Lake City, UT 84112-5350, USA.
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Rodriguez-Carmona A, Pérez-Fontán M, Garca-Naveiro R, Villaverde P, Peteiro J. Compared time profiles of ultrafiltration, sodium removal, and renal function in incident CAPD and automated peritoneal dialysis patients. Am J Kidney Dis 2004; 44:132-45. [PMID: 15211446 DOI: 10.1053/j.ajkd.2004.03.035] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fluid and sodium removal rates may not be equivalent in patients undergoing automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). This may influence compared cardiovascular outcomes in both groups. METHODS The authors compared prospectively the time courses of ultrafiltration, sodium removal, and residual renal function (RRF) in a group of incident patients treated with CAPD (n = 53) or APD (n = 51) for at least 1 year (mean follow-up, 28.9 months; range, 13 to 62). The authors analyzed potential effects of these factors on blood pressure (BP) control and cardiovascular morbidity and mortality. RESULTS Ultrafiltration and sodium removal rates were consistently lower in APD patients (mean differences, 236 mL/d; P = 0.012, and 36 mmol/d; P = 0.018, respectively, end of first year). Moreover, univariate and multivariate analysis indicated that APD therapy results in a moderate, but significantly faster decline of RRF than CAPD therapy. Analysis of clinical outcomes showed that CAPD (versus APD) therapy or higher ultrafiltration or sodium removal rates were associated with a better time course of systolic, but not diastolic, BP. We were unable to identify PD modality, ultrafiltration, or sodium removal rates as independent predictors of cardiovascular morbidity and mortality. CONCLUSION Ultrafiltration and sodium removal rates are consistently lower in incident APD patients than in their counterparts undergoing CAPD. Moreover, RRF declines faster during APD than during CAPD therapy, although this difference may be partially counteracted by a detrimental effect of ultrafiltration on RRF. Aside from a better control of systolic BP in CAPD patients, these differences do not portend significant cardiovascular consequences during the first years of PD therapy.
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