Evaluation of terlipressin-related patient outcomes in hepatorenal syndrome-acute kidney injury using point-of-care echocardiography.

BACKGROUND AND AIMS: Treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI), with terlipressin and albumin, provides survival benefits, but may be associated with cardiopulmonary complications. We analyzed the predictors of terlipressin response and mortality using point-of-care echocardiography (POC-Echo) and cardiac and renal biomarkers. APPROACH: Between December 2021 and January 2023, patients with HRS-AKI were assessed with POC-Echo and lung ultrasound within 6 hours of admission, at the time of starting terlipressin (48 h), and at 72 hours. Volume expansion was done with 20% albumin, followed by terlipressin infusion. Clinical data, POC-Echo data, and serum biomarkers were prospectively collected. Cirrhotic cardiomyopathy (CCM) was defined per 2020 criteria. RESULTS: One hundred and forty patients were enrolled (84% men, 59% alcohol-associated disease, mean MELD-Na 25±SD 5.6). A median daily dose of infused terlipressin was 4.3 (interquartile range: 3.9-4.6) mg/day; mean duration 6.4 ± SD 1.9 days; the complete response was in 62% and partial response in 11%. Overall mortality was 14% and 16% at 30 and 90 days, respectively. Cutoffs for prediction of terlipressin nonresponse were cardiac variables [ratio of early mitral inflow velocity and mitral annular early diastolic tissue doppler velocity > 12.5 (indicating increased left filling pressures, C-statistic: 0.774), tissue doppler mitral velocity < 7 cm/s (indicating impaired relaxation; C-statistic: 0.791), > 20.5% reduction in cardiac index at 72 hours (C-statistic: 0.885); p < 0.001] and pretreatment biomarkers (CysC > 2.2 mg/l, C-statistic: 0.640 and N-terminal proBNP > 350 pg/mL, C-statistic: 0.655; p <0.050). About 6% of all patients with HRS-AKI and 26% of patients with CCM had pulmonary edema. The presence of CCM (adjusted HR 1.9; CI: 1.8-4.5, p = 0.009) and terlipressin nonresponse (adjusted HR 5.2; CI: 2.2-12.2, p <0.001) were predictors of mortality independent of age, sex, obesity, DM-2, etiology, and baseline creatinine. CONCLUSIONS: CCM and reduction in cardiac index, reliably predict terlipressin nonresponse. CCM is independently associated with poor survival in HRS-AKI.

Hepatorenal syndrome misdiagnosis may be reduced using inferior vena cava ultrasound to assess intravascular volume and guide management.

Hepatorenal syndrome (HRS) is a diagnosis of exclusion defined as acute kidney injury (AKI) with cirrhosis and ascites, with serum creatinine unresponsive to standardized volume administration and diuretic withdrawal. Persistent intravascular hypovolemia or hypervolemia may contribute to AKI and be revealed by inferior vena cava ultrasound (IVC US), which may guide additional volume management. Twenty hospitalized adult patients meeting HRS-AKI criteria had IVC US to assess intravascular volume after receiving standardized albumin administration and diuretic withdrawal. Six had IVC collapsibility index (IVC-CI) ≥50% and IVCmax ≤0.7 cm suggesting intravascular hypovolemia, 9 had IVC-CI <20% and IVCmax >0.7 cm suggesting intravascular hypervolemia, and 5 had IVC-CI ≥20% to <50% and IVCmax >0.7 cm. Additional volume management was prescribed in the 15 patients with either hypovolemia or hypervolemia. After 4-5 days, serum creatinine levels decreased ≥20% without hemodialysis in 6 of 20 patients - 3 with hypovolemia received additional volume, and 2 with hypervolemia plus one with 'euvolemia' and dyspnea were volume restricted and received diuretics. In the other 14 patients, serum creatinine failed to persistently decrease ≥20% or hemodialysis was required indicating that AKI did not improve. In summary, fifteen of 20 patients (75%) were presumed to have intravascular hypovolemia or hypervolemia by IVC ultrasound. Six of the 20 patients (40%) improved AKI by 4-5 days of follow-up with additional IVC US-guided volume management, and thus had been misdiagnosed as HRS-AKI. IVC US may more accurately define HRS-AKI as being neither hypovolemic nor hypervolemic, and guide volume management, decreasing the frequency of HRS-AKI misdiagnosis.

Cardiovascular Mapping in Cirrhosis From the Compensated Stage to Hepatorenal Syndrome: A Magnetic Resonance Study.

INTRODUCTION: Arterial vasodilation and hyperdynamic circulation are considered hallmarks of the pathophysiological mechanisms of decompensation in cirrhosis. However, detailed characterization of peripheral, splanchnic, renal, and cardiac hemodynamic have not previously been published in a spectrum from healthy stage to advanced decompensated liver disease with hepatorenal syndrome-acute kidney injury (HRS-AKI). METHODS: We included 87 patients with cirrhosis and 27 healthy controls in this prospective cohort study. The population comprised patients with compensated cirrhosis (n = 27) and decompensated cirrhosis (n = 60); patients with decompensated cirrhosis were further separated into subsets of responsive ascites (33), refractory ascites (n = 16), and HRS-AKI (n = 11). We measured portal pressure and assessed regional blood flow by magnetic resonance imaging. RESULTS: Patients with compensated cirrhosis experienced higher azygos venous flow and higher hepatic artery flow fraction of cardiac index than controls ( P < 0.01), but other flow parameters were not significantly different. Patients with decompensated cirrhosis experienced significantly higher cardiac index ( P < 0.01), higher superior mesenteric artery flow ( P = 0.01), and lower systemic vascular resistance ( P < 0.001) compared with patients with compensated cirrhosis. Patients with HRS-AKI had the highest cardiac output and lowest renal flow of all groups ( P < 0.01 and P = 0.02, respectively). Associations of single hemodynamic parameters were stronger with model for end-stage liver disease than with portal pressure. DISCUSSION: The regional cardiocirculatory changes seem closely linked to clinical symptoms with 3 distinguished hemodynamic stages from compensated to decompensated cirrhosis and, finally, to HRS-AKI. The attenuated renal perfusion despite high cardiac output in patients with HRS-AKI challenges the prevailing pathophysiological hypothesis of cardiac dysfunction as a causal factor in HRS-AKI. Finally, magnetic resonance imaging seems an accurate and reliable noninvasive method to assess hemodynamics and has potential as a diagnostic tool in patients with cirrhosis.

Value of shear wave elastography in predicting hepatorenal syndrome in patients with liver cirrhosis and ascites.

BACKGROUND: Early detection of renal damage in cirrhosis is critical to prevent hepatorenal syndrome (HRS). Although shear wave elastography (SWE) is useful for the assessment of kidney stiffness, no study has yet investigated the clinical feasibility of SWE for predicting HRS. OBJECTIVE: The aim of this study was to evaluate the value of SWE in predicting HRS in patients with cirrhosis and ascites. METHODS: A total of 131 patients with liver cirrhosis and ascites were recruited and followed them for 30 days for the development of AKI. Ultrasonographic examination was performed on all patients at hospital admission. The baseline clinical characteristics, renal biomarkers, renal resistive index (RI) and Young's modulus (YM) were recorded, and their relationship with development HRS was investigated. RESULTS: Sixty-eight patients developed AKI, 23 of them were HRS. Compared with patients in the non-AKI group and non-HRS group, the values of serum cystatin C (CystC), urine neutrophil gelatinase-associated lipocalin (NGAL) and renal RI were significantly increased, while the YM value was significantly decreased in the AKI group and HRS group. Correlation analysis showed that YM was significantly and negatively associated with serum creatinine, serum CystC, urinary NGAL and renal RI in addition to the significant association with the AKI stage. Logistic regression and ROC analysis showed that urine NGAL, renal RI and YM were closely related to the development of HRS. Among them, YM had a good predictive ability in predicting the occurrence of HRS, and the predictive value (AUC = 0.894) was improved when combined with renal RI. CONCLUSION: SWE can indicate renal injury in patients with cirrhosis and ascites. The combination of YM and RI has a good predictive value for the occurrence of HRS.

Imminent rupture of abdominal aortic aneurysm complicated by arteriovenous fistulaization and hepatorenal failure: case report and literature review.

Arteriovenous fistula (AVF) is a rare complication of the abdominal aortic aneurysm (AAA) with complex clinical features. However, AVF and AAA usually cause no symptoms except when they rupture. This case study demonstrated that ultrasonography was a rapid and non-invasive method for the initial assessment of AAA and AVF. A 65-year-old man was admitted to the intensive care unit with hepatic and renal dysfunction. Physical examination revealed an abdominal vascular murmur and bilateral toe discoloration. Ultrasonic examination revealed an AAA and right common iliac artery aneurysm with an AVF located between the right common iliac artery and inferior vena cava. A computed tomography scan confirmed the sonographic findings. We propose that ultrasound should be used more commonly as part of the initial evaluation of the potential and established vascular diseases.

Intervention on Spontaneous Splenorenal Shunt May Decrease the Incidence of Acute Kidney Injury After Liver Transplant.

OBJECTIVES: Spontaneous splenorenal shuntis a type of portosystemic shunt that develops frequently in the setting of chronic portal hypertension. It remains controversial whether shuntinterventions during liver transplant improve transplant outcomes. MATERIALS AND METHODS: We conducted a retrospective comparison between deceased-donor liver transplant recipients who received spontaneous splenorenal shunt intervention and those who did not at a tertiary center between 2012 and 2017. Primary outcomes of interest included intraoperative transfusion requirement, hospital length of stay, acute kidney injury posttransplant, portal vein thrombosis, thrombocytopenia, and 1-year graft and patient survival. RESULTS: Of 268 liver transplant recipients, 50 (18.6%) had large spontaneous splenorenal shunts pretransplant, with 45 patients having available radiologic and outcome data. Nine of 45 patients (20%) received shunt intervention, including pretransplant balloonoccluded retrograde transvenous obliteration (n = 5), intraoperative ligation of the left renal vein (n = 3), and intraoperative direct shunt ligation (n = 1). Demographic data, clinical characteristics, and Model for End-Stage Liver Disease scores were not different between the intervention and the nonintervention groups. Intraoperative transfusion, length of hospitalization, portal vein thrombosis, thrombocytopenia, and 1-year graft and patient survival were also similar between the 2 groups. However, the rate of posttransplant acute kidney injury was significantly lower in patients in the intervention group (0 cases vs 12 cases; odds ratio = 0.73; 95% confidence interval, 0.59-0.90). Patients with no SRS intervention (n = 36) were followed radiologically for 1 year posttransplant, with follow-up data showing complete resolution of spontaneous splenorenal shunt in just 4 patients (15%) and no changes in the remaining patients. CONCLUSIONS: Peritransplant interventions for spontaneous splenorenal shunt may reduce posttransplant acute kidney injury. In patients without intervention, spontaneous splenorenal shunt predominantly persisted 1 year posttransplant.

Breast implant during orthotopic liver transplant to avoid hepatic outflow obstruction.

Donor-recipient size mismatch in liver transplantation is a recognized but uncommon situation. It can lead to a partial or complete obstruction of the inferior vena cava with subsequent hepatic outflow obstruction. Placement of a breast implant in the right upper quadrant of the abdomen during liver transplantation is a technically easy resource and can protect the liver graft from kinking or rotation.

Point-of-Care Echocardiography Unveils Misclassification of Acute Kidney Injury as Hepatorenal Syndrome.

INTRODUCTION: Fulfillment of the diagnostic criteria for -hepatorenal syndrome type 1 (HRS-1) requires prior failure of 2 days of intravenous volume expansion and/or diuretic withdrawal. However, no parameter of volume status is used to guide the need for volume expansion in patients with suspected HRS-1. We hypothesized that point-of-care echocardiography (POCE) may better characterize the volume status in patients with acute kidney injury (AKI) and cirrhosis to ascertain or disprove the diagnosis of HRS-1. METHODS: A pilot observational study was conducted to determine the clinical utility of POCE-based examination of inferior vena cava diameter (IVCD) and collapsibility index (IVCCI) to assess intravascular volume status in patients with cirrhosis and AKI who had been deemed adequately volume-repleted and thereby assigned a clinical diagnosis of HRS-1. Early improvement in kidney function was defined as ≥20% decrease in serum creatinine (sCr) at 48-72 h. RESULTS: A total of 53 patients were included. The mean sCr at the time of volume assessment was 3.2 ± 1.5 mg/dL, and the mean Model for End-Stage Liver Disease score was 29 ± 8. Fifteen (23%) patients had an IVCD <1.3 cm and IVCCI >40% and were reclassified as fluid-depleted, 11 (21%) had an IVCD >2 cm and IVCCI <40% and were reclassified as fluid-expanded, and 8 (15%) had and IVCD <1.3 cm and IVCCI <40% and were reclassified as having intra-abdominal hypertension (IAH). Twelve (23%) patients exhibited early improvement in kidney function following a POCE-guided therapeutic maneuver, that is, volume expansion, diuresis, or paracentesis for those deemed fluid-depleted, fluid-expanded or having IAH, respectively. CONCLUSION: POCE-based assessment of volume status in cirrhotic individuals with AKI reveals marked heterogeneity. Unguided volume expansion in these patients may lead to premature or delayed diagnosis of HRS-1.

Renal intraparenchymal resistive index: the ultrasonographic answer to many clinical questions.

The use of renal resistive indices (RRIs) for the study of renal microcirculation has in the past been proposed for the identification of renal organ damage or even to specifically identify injury to some areas of the renal parenchyma. Nevertheless, according to the most recent evidences from literature this organ-based conception of RRIs has been proven to be partial and unable to explain the RRIs variations in clinical settings of sepsis or combined organ failure of primitively extrarenal origin or, more generally, the deep connection between RRIs and hemodynamic factors such as compliance and pulsatility of the large vessels. The aim of this review is to explain the physiopathological basis of RRIs determination and the most common interpretative errors in their analysis. Moreover, through a comprehensive vision of these Doppler indices, the traditional and emerging clinical application fields for RRIs are discussed.

Point-of-Care Echocardiography Improves Assessment of Volume Status in Cirrhosis and Hepatorenal Syndrome.

The management of patients with cirrhosis along with acute kidney injury is complex and depends in large part on accurate assessment of intravascular volume status. Assessment of intravascular volume status by point-of-care echocardiography often relies solely on inferior vena cava size and variability evaluation; however, this parameter should be interpretated with an understanding of right ventricular function integrated with stroke volume and flow. Attempts to optimize intra-abdominal hemodynamics favorably are clearly problematic when physical examination findings or rudimentary assessments of central venous pressure or change in central venous pressure are used. Here, we have demonstrated the potential utility of point-of-care echocardiography to optimize the hemodynamic state in patients with decompensated cirrhosis along with acute kidney injury. This case is very unique and describes how this technique may have great promise in optimizing the intra-abdominal hemodynamics and predict the timing of large-volume paracentesis in patients with decompensated cirrhosis, which in turn can aid in promoting favorable renal recovery.

Magnetic resonance elastography in the detection of hepatorenal syndrome in patients with cirrhosis and ascites.

OBJECTIVE: Hepatorenal syndrome (HRS) is the most lethal cause of renal impairment in cirrhosis. Magnetic resonance elastography (MRE) is a diagnostic test that characterises tissues based on their biomechanical properties. The aim of this study was to assess the feasibility of MRE for detecting HRS in cirrhotic patients. METHODS: A prospective diagnostic investigation was performed. Renal MRE was performed on 21 hospitalised patients with cirrhosis and ascites. Six patients had HRS, one patient had non-HRS renal impairment, and 14 patients had normal renal function. The MRE-measured renal stiffness was compared against the clinical diagnosis as determined by clinical review alongside laboratory and radiologic results. RESULTS: The MRE-measured renal stiffness was significantly lower in patients with HRS (median stiffness of 3.30 kPa at 90 Hz and 2.62 kPa at 60 Hz) compared with patients with normal renal function (median stiffness of 5.08 kPa at 90 Hz and 3.41 kPa at 60 Hz) (P ≤ 0.014). For the detection of HRS, MRE had an area under the receiver operating characteristic curve of 0.94 at 90 Hz and 0.89 at 60 Hz. MRE had excellent inter-rater agreement, as assessed by Bland-Altman and intraclass correlation coefficient (> 0.9). CONCLUSION: MRE shows potential in the detection of HRS. KEY POINTS: • Magnetic resonance elastography (MRE) shows promise in the detection of hepatorenal syndrome. • MRE has the potential to track renal disease in a clinical population. • MRE is a reliable diagnostic test with excellent inter-rater agreement.

[Index resistance in renal ultrasound: what is the clinical significance?]. / Gli indici di resistenza ecografici in nefrologia: quale significato clinico?

In the area of renal diagnosis, B-mode ultrasound allows for the study of renal morphology, while power color Doppler is of strategic importance not only for the qualitative and quantitative information it provides on renal vasculature, but also because it allows for the measurement of 'Index Resistance'. This is the ratio between the peak systolic speed [VPS] minus the telediastolic speed [VTD] and the VPS: [VPS-VTD/VTD]), now one of the most sensitive parameters in the study of renal pathologies through the quantification of changes in renal plasma flow. The reliability of the measurement of IR is dependent on accurate methodology, such as sampling at the level of the interlobar or arcuate arteries of 3 to 5 waves of similar dimensions in three different areas of the kidney, etc. Reliability also depends on careful analysis of the value obtained, owing to the confounding influence of peripheral resistance in addition to many other factors, including tachy-brady-arrhythmias, severe hypotension, and perirenal or subcapsular fluid collections. In adults an average IR of < 0.70 is considered normal, although this figure varies with age, giving higher values in children in the first years of life and in the elderly. The color Doppler measurement of IR at the level of the interlobar artery has been proposed as an indicator for differential diagnosis of acute or chronic nephropathies: for example, the ratio was higher in acute pathologies with vascular and tubulo-interstitial involvement, but not in those with glomerular involvement. This review aims to highlight clinical situations in which the study of intrarenal IR can provide useful information on the physiopathology of renal disease in both the native and in the transplanted kidney, as illustrated by the alterations of the morphology of the Doppler wave that are caused by variations in vascular resistance, hydrostatic capillary pressure and pressure inside the urinary tract.

Native renal function after combined liver-kidney transplant for type 1 hepatorenal syndrome: initial report on the use of postoperative Technetium-99 m-mercaptoacetyltriglycine scans.

Type 1 hepatorenal syndrome (HRS) is characterized by rapid deterioration of renal function. We sought to assess native kidney function after combined kidney-liver transplant (CLKTx) performed for type 1 HRS. We performed a retrospective, cross-sectional, single-center study. All patients with Type 1 HRS who received a CLKTx at the University of California, San Francisco from 1997 to 2007 were screened for enrollment. Patients with a baseline estimated glomerular filtration rate (eGFR) ≥30 ml/min/1.73 m(2) were eligible. Twenty-three patients were identified and consented to receive a Technetium-99 m-mercaptoacetyltriglycine (MAG3) nuclear scan to measure the native kidney contribution to overall renal function. Only 4 of the 23 subjects (17.4%) demonstrated native renal function that consisted of a contribution ≥50% of total renal function. Several factors and comorbidities such as age, gender, race, duration of HRS, need for and duration of renal replacement therapy, need for pressors, urine sodium, proteinuria, and use of octreotide/midodrine were analyzed and not found to be significant in predicting native renal function. The assessment of post-transplant native renal function following CLKTx may allow for improved accuracy in identifying the patients in need of CLKTx, and thus allow for greater optimization of dual-organ allocation strategies in patients with concomitant liver and renal failure.

Intrarenal resistance index (RI) as a predictor of early renal impairment in patients with liver cirrhosis.

BACKGROUND: Despite its functional nature, hepatorenal syndrome (HRS) is associated with a poor prognosis and the only effective treatment is liver transplantation. It is very important to diagnose renal impairment in cirrhosis patients at an early stage before overt HRS develops. In patients with cirrhosis the early renal impairment or renovascular vasoconstriction can be predicted by renal arterial resistance index (RI). Our study aimed to compare RI in healthy controls versus patients with liver cirrhosis with and without ascites and assess its value for predicting subsequent renal status. METHODS: Patients were divided into 2 groups with 50 patients in each group. Group 1 contained patients with cirrhosis without ascites and group 2 contained cirrhosis patients with ascites. All patients were subjected to detailed clinical examination, laboratory investigations and abdominal doppler ultrasound with renal RI measurements. Patients were followed for 6 months. RESULTS: RI was significantly higher in cirrhotic patients as compared to healthy controls (0.62 vs. 0.52, p< 0.01). In patients with cirrhosis, RI was significantly greater in patients with ascites than those without ascites (0.70 vs. 0.62, p < 0.01). RI >0.70 was significant independent predictor of subsequent HRS development (p = 0.006) CONCLUSIONS: Intrarenal RI measurement can be used as a predictor of HRS and may be further validated for regular monitoring of cirrhotic patients at risk of developing renal impairment.

Renal haemodynamics in patients with liver cirrhosis assessed by colour ultrasonography.

Colour Doppler flow imaging was used in this prospective, cross-sectional study to analyse renal haemodynamics in 50 cirrhotic patients and 15 healthy controls. Mean renal arterial resistive index (RI) was higher in cirrhotic patients than in healthy controls. Mean RI was also higher in cirrhotic patients with non-refractory ascites than in those without ascites, suggesting that the degree of renal vasoconstriction varies with the severity of ascites. A gradient of RI values across the main renal artery, interlobar artery and interlobular renal artery was retained in cirrhotic patients even in the decompensatory stage with non-refractory ascites but was not present in the decompensatory stage with refractory ascites. The disappearance of this gradient may be an important prognostic factor in the development of hepatorenal syndrome (HRS). An inverse correlation between creatinine clearance and interlobular arterial RI was shown for all cirrhotic patients suggesting that even patients with refractory ascites are in a prophase of HRS.

Hepatorenal polycystic disease and fever: diagnostic contribution of gallium citrate Ga 67 scan and fluorine F 18 FDG-PET/CT.

A cyst infection was suspected in a patient who was on haemodialysis for renal failure secondary to hepatorenal polycystic disease with persistent fever and pain in right hypochondrium despite antibiotherapy. Radiologic exams (ultrasonography, computed tomography [CT]), however, did not show signs of infection. For surgical removal of the infected cyst, a precise location was required. This report shows how functional imaging, gallium citrate Ga 67 scan, and fluorine F 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) revealed which cyst was infected; however, the fused image provided by PET/CT showed the precise, required location. The infected cyst was located on the right kidney. A week later, after nephrectomy, all symptoms disappeared.

Effects of terlipressin on systemic, hepatic and renal hemodynamics in patients with cirrhosis.

BACKGROUND AND AIM: Terlipressin has been shown to be effective in the management of hepatorenal syndrome. However, how terlipressin exerts its effect on the renal artery is unknown. The aim of the present study was to assess the effects of terlipressin on systemic, hepatic and renal hemodynamics in cirrhosis. METHODS: Twenty-eight patients with cirrhosis and portal hypertension were studied. Systemic and hepatic hemodynamics, hepatic and renal arterial resistive indices and neurohumoral factors were measured prior to and 30 min after intravenous administration of 1 mg terlipressin (n = 19) or placebo (n = 9). RESULTS: After terlipressin, there were significant increases in both mean arterial pressure (P < 0.001) and systemic vascular resistance (P < 0.001), whereas heart rate (P < 0.001) and cardiac output (P < 0.001) decreased significantly. There was a significant decrease in the hepatic venous pressure gradient (P < 0.001). Portal venous blood flow also decreased significantly (P < 0.001). The mean hepatic arterial velocity increased significantly (P < 0.001). Although there was a significant decrease in the hepatic arterial resistive index (0.72 +/- 0.08 to 0.69 +/- 0.08, P < 0.001) and renal arterial resistive index (0.74 +/- 0.07 to 0.68 +/- 0.07, P < 0.001), portal vascular resistance was unchanged (P = 0.231). Plasma renin activity decreased significantly (P < 0.005), and there was a significant correlation between this decline and the decrease in renal arterial resistive index (r = 0.764, P < 0.005). The effects of terlipressin on systemic, hepatic and renal hemodynamics were observed similarly in patients with and without ascites. Placebo caused no significant effects. CONCLUSION: Terlipressin decreases hepatic and renal arterial resistance in patients with cirrhosis.

Renal duplex Doppler ultrasound in patients with HCV related liver cirrhosis.

AIM: To study the renal resistive index (RI) and pulsatility index (PI) measured by renal Doppler in various stages of liver cirrhosis and their values to detect cirrhotic patients at risk for developing the hepatorenal syndrome. METHODS: This study included 60 cirrhotic patients divided into 4 groups (15 patients each): compensated liver cirrhosis (group A), diuretic responsive ascites (group B), refractory ascites (group C), hepatorenal syndrome (group D) and ten healthy persons as the control group (E). All patients were subjected to detailed history taking and clinical examination. Laboratory investigations included simple urine analysis, complete blood picture, liver function tests, blood urea and serum creatinine, serum sodium and serum potassium, 24-hour urine collection for sodium concentration, creatinine concentration and protein concentration. Ultrasonographic examination and renal duplex Doppler ultrasonography were undertaken to assess the RI and PI. RESULTS: The RI of both interlobar and arcuate arteries was significantly higher in all patient groups than in the control group (p<0.01). The RI was significantly higher in patients with refractory ascites than in patients with diuretic responsive ascites, and also in patients with diuretic responsive ascites than in patients with compensated cirrhosis (p<0.01); in patients with hepatorenal syndrome than in patients with diuretic responsive ascites and patients with compensated cirrhosis (p<0.0001). The PI was significantly higher in all patients groups than in the control group (p<0.01) and in patients with refractory ascites than in patients with diuretic responsive ascites and was also higher in patients with responsive ascites than in patients with compensated cirrhosis (p<0.0001). Also, the PI was significantly higher in patients with hepatorenal syndrome than in patients with responsive ascites and patients with compensated cirrhosis (p<0.0001). Creatinine clearance in patients with the hepatorenal syndrome was significantly lower than that of other different groups (p<0.0001) but there was no significant change in creatinine clearance between patients with compensated cirrhosis and control group. While creatinine clearance in patients with diuretic responsive ascites was significantly higher than that in patients with compensated cirrhosis (p<0.05) there was no significant change between patients with diuretic responsive ascites and patients with refractory ascites. CONCLUSION: Both renal resistive index and pulsatility index increase with the degree of hepatic decompensation. Renal duplex ultrasound which is a non-invasive, simple and easy method to study intrarenal hemodynamics in patients with liver cirrhosis may predict patients at risk of hepatorenal impairment.