Congestive Cardiac Failure Patients Research Articles

Pneumococcal vaccine uptake and its associated factors among adult patients with congestive cardiac failure seen in a tertiary facility in Lagos, Nigeria

Background: Patients with congestive cardiac failure (CCF) are at increased risk of morbidities and mortality associated with pneumococcal infections and thus should be vaccinated against Streptococcus pneumoniae. However, there is dearth of scientific data on pneumococcal vaccine uptake in this environment. This study set out to assess the vaccination status and its associated factors among CCF patients in Lagos State University Teaching Hospital (LASUTH), Lagos, Nigeria.
 Methodology: A questionnaire based cross-sectional study of one hundred patients with CCF conducted at the adult cardiology out-patient clinic of LASUTH between December 2021 and March 2022. Socio-demographic and clinical characteristics were recorded as well as Pneumococcal vaccination status, source of vaccination, challenges and reasons for non-vaccination. The likelihood of recommending vaccination for others was also obtained.
 Results: The mean age of the study population was 51.55±16.36 years (range 21-78 years). The male to female ratio was 56:44. Pneumococcal vaccination rate was 9% with only 4% fully vaccinated. Lack of information about vaccine was the commonest reason for non-vaccination. Healthcare providers were the source of vaccine information in only 58% of the vaccinated subjects. Majority of the vaccinated respondents (67%) had their vaccines outside the country and most of them will likely recommend vaccination to others.
 Conclusion: Pneumococcal vaccination rate among CCF patients was poor. Better patients’ education and prompt vaccine recommendation by the managing physicians will improve vaccination uptake. A National guideline for adult pneumococcal vaccine in Nigeria is desirable.

Clinico-Demographic Study of Chronic Renal Disease Patients Presenting with Congestive Cardiac Failure at a Tertiary Level of Hospital in Dhaka City

Background: Heart failure (HF) is a major public health issue, and it is associated with a high rate of mortality, morbidity,
 Objective: The purpose of the present study was to assess the demographic and clinical characteristics of the chronic renal disease patient with congestive cardiac failure (CCF).
 Methodology: This cross-sectional study was carried out in the Department of Medicine and Department of Cardiology in Dhaka Medical College Hospital, Dhaka, Bangladesh for six months after approval of the protocol on patients suffering from CCF. Study population was selected in the study group based on age more than 18 years of both sex and diagnosed case of CCF.
 Results: A total 100 patients were included and among them majority of the patients were aged between 51 to 60 years (32.0%). Among them 70.0% cases were male and 30.0% cases were female. About 58.0% cases were living in rural area and 46.0% cases of total subjects had a family income of 20,000-40,000 BDT. Co-morbidities of CCF patients of the study population showed that 53% had hypertension, 48% had ischemic heart disease, 34% had DM, 20.0% had dyslipidaemia, 16% had anaemia, 14.0% had asthma or COPD and rest 8% had history of atrial fibrillation. About 100.0% patients had shortness of breath along with 92.0% bilateral basal crepitation on auscultation; 80.0% had orthopnoea and 66.0% had raised JVP with 64.0% bilateral ankle edema.
 Conclusion: In conclusion males with hypertension and sedentary life style suffer from kidney diseases.
 Journal of Current and Advance Medical Research, January 2022;9(1):21-25

Effect of exercise program on health-related Quality of Life (QOL) in Congestive Cardiac Failure patients

Heart Failure is a common cardiovascular condition with increasing incidence and prevalence. Congestive cardiac failure continues to be a major cause of death throughout the world despite dramatic advances made in the treatment over the last 25 years. As it is growing and people are affected by it, the nurse has an important role in helping the people to live with the disease and control it through various preventive and therapeutic measures. Exercise and education programs are designed to improve the patient’s quality of life after a heart failure or another heart problem. It includes a program of structured exercise that is now generally believed not only to improve morbidity but also to reduce mortality in patients who have suffered a CCF. Material and Method: A Quasi-experimental post-study only design without a control group approach was undertaken in Pravara Rural Hospital. A total of 30 congestive cardiac failure patients were randomly assigned to receive the intervention of the Exercise program. The nurse investigator provided 05 minutes exercise program. Assessment of effectiveness is performed by evaluating Quality of Life. The data were analyzed with descriptive and inferential statistics, wherever required. Results: It was found that the exercise program significantly improved QOL. A statistically significant difference was found between the group QOL (t=15.47) there was a significant association found between socio-demographic characteristics (0 . 840 dna 8.8.0 ) at p<0.05 level. Conclusion: The study outcome revealed that the exercise program was found to be effective in improving the QOL among congestive cardiac failure patients. Hence it should be emphasized that exercise programs should be practiced for the vulnerable CCF patient with routine care.

Effect of exercise program on health-related Quality of Life (QOL) in Congestive Cardiac Failure patients

Background:Heart Failure is a common cardiovascular condition with increasing incidence and prevalence. Congestive cardiac failure continues to be a major cause of death throughout the world despite dramatic advances made in the treatment over the last 25 years. As it is growing and people are affected by it, the nurse has an important role in helping the people to live with the disease and control it through various preventive and therapeutic measures. Exercise and education programs are designed to improve the patient’s quality of life after a heart failure or another heart problem. It includes a program of structured exercise that is now generally believed not only to improve morbidity but also to reduce mortality in patients who have suffered a CCF. Material and Method: A Quasi-experimental post-study only design without a control group approach was undertaken in Pravara Rural Hospital. A total of 30 congestive cardiac failure patients were randomly assigned to receive the intervention of the Exercise program. The nurse investigator provided 05 minutes exercise program. Assessment of effectiveness is performed by evaluating Quality of Life. The data were analyzed with descriptive and inferential statistics, wherever required. Results: It was found that the exercise program significantly improved QOL. A statistically significant difference was found between the group QOL (t=15.47) there was a significant association found between socio-demographic characteristics (0 . 840 dna 8.8.0 ) at p<0.05 level. Conclusion: The study outcome revealed that the exercise program was found to be effective in improving the QOL among congestive cardiac failure patients. Hence it shouldbe emphasized that exercise programs should be practiced for the vulnerable CCF patient with routine care.

Prevalence of deep vein thrombosis in congestive cardiac failure patients

BACKGROUND: Congestive cardiac failure (CCF) and deep vein thrombosis (DVT) may coexist in a patient. The prevalence of DVT has been reported up to 34.1% in CCF patients, and its presence may increase the morbidity and mortality of CCF patients. The presence of DVT may increase the morbidity and mortality of CCF patients. With this background in mind, we conducted a study to know the prevalence of DVT in CCF patients from our part of the world.MATERIALS AND METHODS: An analytical cross-sectional study was carried out over a period of 1 year from March 2015 to February 2016 on 50 patients admitted with CCF to our hospital. After obtaining information on underlying comorbid illness, duration of CCF symptoms, and preliminary investigations, the patients were subjected to venous Doppler ultrasound.RESULTS: A total of 50 patients admitted with the diagnosis of CCF were enrolled in this study. The mean age of patients was 63.28 ± 9.5 years. The mean body mass index of the patients was 24.48 ± 2.8 kg/m2. Five out of 50 patients were found to have deep vein thrombosis in our study. The duration of symptoms of more than 10 days before seeking medical consultation was statistically significant in patients of CCF with DVT.CONCLUSION: In our study, 10% of patients with CCF had DVT on venous Doppler ultrasound. A longer duration of CCF symptoms before seeking medical consultation was significantly associated with DVT in our patients.

Impairment of cognitive functions in congestive cardiac failure patients.

Background:Congestive cardiac failure (CCF) patients show several neuropsychological impairments and reduced quality of life and impairment of functioning.Objective:The objective of this study was to recognize the deficits in cognition in CCF patients and comparing this cognitive function in the same number of healthy participants.Materials and Methods:A case–control study design was adopted. The study was conducted in the cardiology department of a tertiary care hospital. Convenience sampling was done. Twenty-one participants with CCF (New York Cardiac Association – Class III severity) and 21 healthy participants participated in the study. Each participant in the control group was screened by the General Health Questionnaire-12-item version. We evaluated both groups for the various domains of their cognitive function using a comprehensive battery of neuropsychological tests. Student's t-test was used to analyze the difference between the means for the study variables.Results:We observed that attention, executive function, working memory, psychomotor speed, and visuospatial ability were impaired in the patients with CCF compared to the controls. However, they did not differ significantly in language function.Conclusions:Cognitive functioning is significantly impaired in CCF patients.

Does Subclinical Hypothyroidism Affect Hospitalization Outcomes and Mortality in Congestive Cardiac Failure Patients?

ObjectiveThis study aimed to determine the differences in hospitalization outcomes among patients admitted for congestive cardiac failure (CCF) with underlying subclinical hypothyroidism (SCH).MethodsThis retrospective case-control study used data from the nationwide inpatient sample (NIS) for the years 2012–2014. We identified cases with CCF as the primary diagnosis and SCH as the secondary diagnosis using validated ICD-9-CM codes and controls with CCF only. The differences in hospitalization outcomes and hospital characteristics were quantified using the multinomial logistic regression model (adjusted odds ratio (aOR)).ResultsA total of 143,735 CCF patients were enrolled in this study, and 73,440 cases had IH. About 31.8% of SCH patients were hospitalized for more than four days (median) compared to 44.7% patients without SCH (P < .001). The median hospitalization charges per admission for CCF was $20,312. CCF patients with SCH had lower odds of longer hospitalization (aOR = .709, 95% CI .660-.762, P < .001) and higher hospitalization charges (aOR = .783, 95% CI .728-.841, P < .001) compared to CCF patients without SCH. CCF patients with SCH had two times higher odds of minor morbidity (aOR = 2.276; 95% CI 2.105-2.462; P < .001) but lower odds of major morbidity (aOR = .783; 95% CI .728-.841; P < .001). Inpatient mortality with SCH patients (2%) compared to 3.6% patients without SCH (P < .001). CCF patients with SCH had lower odds of in-hospital mortality (aOR = .547; 95% CI .496-.604; P < .001). CCF patients with SCH had higher odds of being seen in rural non-teaching hospitals (aOR = 1.696; 95% CI 1.572-1.831; P < .001). Also, CCF patients with SCH had the highest likelihood of presence in the western region of the United States (aOR = 149.924; 95% CI 110.497-203.419; P < .001) followed by the southern region (aOR = 31.431; 95% CI 26.066-37.900; P < .001).ConclusionsAmong CCF with SCH patients during hospitalization, we observed a variation in hospitalization outcomes, including inpatient length of stay and cost, morbidity, and in-hospital mortality. We found no significant increase in mortality and major morbidity in CCF patients with SCH. There were differences in the hospital characteristics between CCF patients with and without SCH. Thus, hospital bed size, location, and teaching status act as predictors for a co-diagnosis of SCH in CCF. Further research is needed to guide the development of clinical care models for targeting early diagnosis and treatment to determine whether thyroid hormone replacement would be beneficial for CCF patients with SCH and improve quality of care in these patients.

Should We Confine the Cardio Hepatic Syndrome Only in Congestive Cardiac Failure Patients?

AbstractIntroduction: Liver function abnormalities are not uncommon in patients with heart failure. Multiple reasons have been cited like impaired perfusion or elevated right-sided cardiac pressures, or are secondary to drug toxicity. In this study, we analyzed the patients admitted at our center to detect the profile of cardio-hepatic syndrome. This analysis may explore new etiologies for cardio-hepatic syndrome.Materials And Methods: This is an observational retrospective study done at our institute. We collected the liver function tests which were conducted in patients admitted in cardiology in 2015 (Jan to Dec at our center. Patients having abnormal liver function tests were analyzed for various etiologies. SGPT value &gt; 45 Units per liter is considered as elevated.Results: Out of the patients admitted to cardiology department, SGPT and SGOT values are available in 2803 and 4577 patients respectively. Mean age of these patients was 58±12.9 yrs.In SGPT group 1881 were males. In 432(15.4%) patients SGPT was elevated. In them 326 (76%) were males. Among the patients in whom SGPT is elevated, also had elevated CPK and CPK-MB due to MI were in 154 patients (35.6%). In 24 patients (5.6%) SGPT was elevated along with NT pro BNP levels. Rest of the SGPT elevated patients (254 – 58.8%) does not come under CCF or MI category and out these patients about 146 patients were on either on statin or other drugs which can increase the liver enzymes. Still we require to evaluate the cause of hepatic abnormality in 106(24.5%) patients admitted with cardiac disease.Conclusions: Cardio-hepatic syndrome is not just confined to heart failure. Though heart failure, MI and drug induced hepatic dysfunction accounted for 75.5% of the etiology, we require to see present unknown the etiology for this sub group of cardio hepatic syndrome. Further elucidating the etiology for the remaining 24.5% cardio hepatic syndrome is of much interest.

Effectiveness of Back Massage on Sleep Pattern among Patients with Congestive Cardiac Failure.

Background:Sleep plays an important role in congestive cardiac failure (CCF). Back massage reduces anxiety, discomfort, and physical suffering in CCF patients. Study objective is to assess sleep pattern in CCF patients before and after back massage.Materials and Methods:A quasi-experimental study was conducted in Pravara Rural hospital, Loni, India over 4 months in 2016. Thirty CCF patients were included in the study with purposive sampling. Nurse investigator performed 20-min back massage thrice daily, 5 min for each step from the day of admission till discharge. In back massage, effleurage, stroking, kneading, and assessment of effectiveness was recorded using the Pittsburg sleep quality index.Results:Thirty CCF patients were included, out of which individuals aged >65, 56–65, and 35–45 years age group were 40%, 24%, and 13%, respectively. Twenty-four had left and 6 had right heart failure. Distribution of mean and standard deviation of pretest for sleep quality was 9.50 (3.14), indicating poor sleep quality. Posttest, the mean score was 4.47 (0.89), indicating good quality sleep. Eleven patients had >8 h of sleep, 15 patients had 6–8 h of sleep, whereas 4 patients had less than 6 h of sleep pretest. Posttest, 22 patients had >8 h and the remaining had 6–8 h of sleep.Conclusions:Back massage technique is safe and cost-effective in CCF patients, by which the quality and duration of sleep is improved. It can be a part of the standard treatment.

Assessment of adherence to cardiovascular medicines in rural population: An observational study in patients attending a tertiary care hospital.

Introduction:Nonadherence to cardiovascular medicines is a major concern. It increases the morbidity and mortality of cardiovascular patients. The work was conducted to evaluate the adherence to cardiovascular medicines in patients of rural India.Methods:The study was conducted in the Department of Medicine involving rural patients with essential hypertension (HTN), congestive cardiac failure (CCF), and ischemic heart disease (IHD) over 12 months period. Patients were prescribed with cardiovascular medicines at the initial visit and adherence to medicines was assessed in the subsequent visit. Four items Morisky's Medication Adherence Scale (MMAS-4) was used for assessing medication adherence. Patients were considered adherent to medication if they answered negatively to all four questions.Results:Overall adherence to medication was 20.83%, 28.37% and 32% in HTN, CCF, and IHD patients, respectively. Nonadherence was highest in patients of HTN. Among the four reasons of nonadherence assessed by MMAS-4, carelessness was the most common and forgetfulness was the least common cause of nonadherence in all the three groups of patients.Conclusion:Patients of rural India adhere poorly to cardiovascular medicines. Nonadherence should be considered as a public health problem. Strategies for detecting the level of adherence of cardiovascular medicines, its barriers, and subsequent interventions should be developed by policy-makers to reduce morbidity and mortality due to cardiovascular disorders.

TEE-guided left ventricular epicardial pacing lead placement for cardiac resynchronization therapy

Biventricular pacing has demonstrated improvement in cardiac functions in treating congestive cardiac failure patients. Recent trials have proven the clinical and functional benefits of cardiac resynchronization therapy in severe heart failure and intraventricular cardiac delays, mainly left bundle branch block. Biventricular pacing improves the exercise tolerance, quality of life, systolic heart function, reduces hospitalization and slows progression of the disease. A 54-year-old lady, a known case of dilated cardiomyopathy, was on biventricular pacing since 2 years. She presented in emergency with sudden deterioration of dyspnea to NYHA class III/IV. When investigated, the coronary sinus lead was found displaced; thus, left ventricle (LV) was not getting paced. After multiple failures to reposition the coronary sinus lead, it was decided to surgically place the epicardial lead for LV pacing under general anesthesia. Lateral thoracotomy was done and LV pacing lead was placed at different sites with simultaneous monitoring of cardiac output (CO) and stroke volume (SV) by transesophageal echocardiography (TEE). Baseline CO and SV were 1.9 l/min and 19.48 ml respectively and increased at different sites of pacing at LV, the best CO and SV were 4.2 l/min and 42.39 ml respectively on lateral surface. Intraoperative TEE can calculate beat to beat stroke volume and thus CO and helps to choose optimal site for placement of epicardial pacing lead.

Do Patients in Congestive Cardiac Failure Undergoing Cardiac Surgery Demonstrate Worse Outcomes Compared with Those with a History of Cardiac Failure?

Cardiac surgery in patients with symptoms of congestive cardiac failure (CCF) carries a significant risk of mortality and morbidity. Except for emergencies and in unstable cases, the recommendation has been to delay the operation until the patient is fully recovered. The objective of this study was to determine the consequences of cardiac surgery in patients with acute decompensated heart failure and to compare their outcomes with the results of the operation in patients with previous CCF. We compared the outcomes of patients with CCF (n = 707) at the time of cardiac surgery (valve replacement or coronary artery bypass grafting [CABG]) with those with a history of CCF (n = 1583). The EuroSCORE was significantly higher in CCF patients (P < .001). Impaired renal function was also more commonly observed in patients with CCF (P < .001). After adjusting for preoperative characteristics, we compared the 2 groups with respect to postoperative complications, postoperative creatine kinase MB values, and in-hospital mortality. Before adjusting for preoperative characteristics, we found that in-hospital mortality (15.5%) and postoperative complications, such as arrhythmias (31%), renal failure (19%), stroke (4.7%), and myocardial infarction (MI) (3%), were significantly higher in the CCF group than in those with a previous history of CCF. When the patients were matched for preoperative characteristics, the rates of postoperative MI and arrhythmia were the main complications that were significantly higher in the CCF group, compared with the patients with previous CCF. The 2 groups were not significantly different with respect to in-hospital mortality. The results were not affected by the type of procedure (valve or CABG), and the main factor influencing mortality was the EuroSCORE. Despite the significant risk of mortality and morbidity in patients with current CCF, cardiac surgery to reverse the cause should not be delayed in these patients, because doing so may lead to further deterioration. Other risk factors, however, should be taken into consideration on an individual basis.

070 Do patients in congestive cardiac failure undergoing cardiac surgery demonstrate worse outcome compared to those recovered from a recent cardiac failure?

Objectives Cardiac surgery in patients with congestive cardiac failure (CCF) carries a significant risk of mortality and morbidity. Except for emergencies and in unstable cases, it has been recommended to delay the operation until the patient is fully recovered. The objective of this study was to determine the consequences of cardiac surgery in patients with current CCF undergoing surgery, and compare their outcome with the results of the operation in patients with a previous history of CCF. Methods We have compared the outcome of patients who had CCF (n=707) at the time of cardiac surgery (Valve replacement or CABG), with those who had a previous history of CCF (n=1581) but recovered prior to their operation. The EuroScore was significantly higher in CCF patients (p Results Prior to adjusting for the pre-operative characteristics, in-hospital mortality (15.5%), post-operative complications, such as arrhythmias (31%), renal failure (19%), stroke (4.7%) and myocardial infarction (3%) were significantly higher in the CCF group compared to those with a previous CCF (Abstract 70 Table 1). When matched for the pre-operative characteristics, post-operative MI and arrhythmia were the main complications that were found to be significantly higher in current CCF group (Abstract 70 Table 2), but in-hospital mortality was not significantly different between the two groups. In addition, the results were not affected by the type of the procedure (valve or CABG). The main factor influencing post-operative mortality was EuroScore of the patient. Conclusion Despite the significant risk of morbidity and mortality in patients with current CCF, cardiac operation to treat the cause should not be delayed, as this may lead to further deterioration of patient9s condition. However, other risk factors should be taken into consideration for each individual. In other words, CCF should not be the main factor for postponing or denying a cardiac operation.

P322 Evaluation of the short-term effect of cardiac resynchronization therapy to reserve left ventricular structural remodeling in congestive cardiac failure patients by echocardiography

P322 Evaluation of the short-term effect of cardiac resynchronization therapy to reserve left ventricular structural remodeling in congestive cardiac failure patients by echocardiography

Jaundice as a presentation of heart failure

As many as 55% of 42 patients with severe congestive cardiac failure (CCF) (characterized by a cardiac index of 1.5 L/min/m2 or less) may have raised serum alkaline phosphatase,1 yielding a prevalence of this liver enzyme derangement twice that documented by van Lingen et al. (September 2005 JRSM2). Accordingly, jaundice and/or serum alkaline phosphatase hotline would be more informative than an exclusively jaundice hotline service for elucidating the distinguishing features (if any) of those patients in whom CCF co-exists with potentially treatable choledocholithiasis. This scenario is especially likely in the elderly, in whom the age-related nature of the two disorders3,4 makes it increasingly likely that they will co-exist by pure chance; the confusion between the two disorders is compounded when co-prescription of warfarin is complicated either by idiosyncratic warfarin-related cholestasis5 or by anticoagulant-related haemobilia.6 I agree that correct evaluation of jugular venous pressure (JVP) is crucial to the differential diagnosis between CCF-related jaundice and other causes of jaundice. [I would add that the time is long overdue for non-cardiology internists to abandon the so-called ‘JVP raised to 2 cm’ calibration so widely prevalent in the clerking of CCF patients]. However, this is not the whole story. The biochemical stigmata of CCF-related jaundice can be indistinguishable from those of choledocholithiasis,1 justifying a vigilant awareness of the possibility of the co-existence of the two disorders in every CCF patient in whom serum alkaline phosphatase of hepatic origin is elevated to twice or more of the upper limit of normal, irrespective of the severity of jaundice, and, possibly, even regardless of whether or not the patient is jaundiced.7

Functional consequences of endothelial nitric oxide synthase uncoupling in congestive cardiac failure.

Impaired endothelium-mediated vasodilatation (EMVD) in congestive cardiac failure (CCF) has been linked to decreased nitric oxide (NO) bioavailability because of its interaction with vascular superoxide (O2*-), derived predominantly from NAD(P)H-dependent oxidases. When uncoupled from essential cofactors, endothelial nitric oxide synthase (eNOS) produces O2*-. We studied the functional consequences of eNOS uncoupling in relation to EMVD in patients with CCF. We employed the platelet as a compartmentalized ex-vivo model to examine O2*- and NO production. When eNOS is functioning normally, incorporation of Nomega-Nitro-L-Arginine methyl ester (L-NAME, 1 mmol/L), results in increased O2*- detection, as inhibition of NO production prevents NO scavenging of O2*-. This was observed in controls and 9 of the CCF patients, in whom O2*- detection increased by 63% and 101%, respectively. In the remaining 9 CCF patients, incorporation of L-NAME reduced O2*- production by 39%, indicating O2*- production by eNOS uncoupling. Detection of platelet-derived NO was significantly greater in eNOS-coupled platelets compared with the uncoupled group (2.8+/-1.4 versus 0.9+/-0.4 pmol/108 platelets, P=0.04). Endothelium-dependent and -independent vasodilator responses to acetylcholine and sodium nitroprusside recorded using venous occlusion plethysmography were significantly impaired in patients exhibiting eNOS uncoupling. This study provides first evidence that platelet eNOS can become uncoupled in human CCF. Impaired endothelium-dependent and -independent vasodilator responses and diminished platelet-derived NO production occurred in association with enzyme uncoupling.

Pathophysiology of renal fluid retention

Central to a unifying hypothesis of body fluid regulation is maintenance of arterial circulatory integrity. This may be disturbed by arterial underfilling, either from reduction in cardiac output or by peripheral arterial vasodilation. In cardiac failure (CF), cardiac output falls and the nonosmotic release of arginine vasopressin (AVP) and expression of AVP mRNA in the hypothalamus are stimulated. V2 AVP receptor antagonists correct the impaired water excretion in rats with low-output CF, increase solute free water clearance, correct the hyponatremia in congestive CF patients, and normalize urinary concentrations of the aquaporin-2 (AQP-2) water channels. In conditions associated with peripheral vasodilation, such as cirrhosis, nonosmotic release of AVP also occurs, and AQP-2 gene expression in the rat kidney is up-regulated. In cirrhosis, nitric oxide-mediated vasodilation occurs early prior to water retention. V2 antagonists reverse the latter. In normal pregnancy, plasma AVP is relatively high for the degree of hypoosmolality. Pregnant rats up-regulate AQP-2 in the renal papilla, an effect reversed by V2 receptor antagonists. This supports the hypothesis that AVP is an important mediator of renal water retention in pregnancy. In summary, AVP-mediated water retention through collecting duct AQP-2 water channels is important in both low-output CF and high-output states such as cirrhosis and pregnancy. V2 receptor antagonists reverse the water retention and down-regulate AQP-2 water channels.