Non-selective beta-blockers impair global circulatory homeostasis and renal function in cirrhotic patients with refractory ascites

•Refractory ascites is a distinct hemodynamic state in cirrhosis wherein sympathetic activation and systolic function are upregulated.•In this setting, renal perfusion and function depend critically on cardiac systolic function and sympathetic hyperactivation.•Reduced systolic function by β-blockade critically diminishes renal perfusion impairing renal function.•The therapeutic window for non-selective β blockers in cirrhosis precedes refractory ascites.