Effect of Midodrine on HVPG in Advanced Chronic Liver Disease

* Primary objective: HVPG response after administration of midodrine as defined by decrease in HVPG by \> 20 % from baseline or to less than equals to 12 mmHg. * Secondary objectives: Change in HVPG, SVR, heart rate, cardiac output, cardiac index, Blood pressure (systolic, diastolic and mean). Methodology: Consecutive patients of chronic liver disease in the Institute (admitted or coming to OPD) as per the inclusion and exclusion criteria will be studied. * Study Population: Patients of advanced chronic liver disease admitted or OPD patients in ILBS * Study Design: A single arm interventional study * Study Period: 6 months * Inclusion Criteria: i) CLD with grade III ascites with Na \< 130 / Systolic BP \< 90 / type 2 HRS(n=30 ) (ii) ACLF (APASL criteria) with Na \< 130 / Systolic BP \< 90 / AKI (n=30) * Exclusion Criteria: age \< 18 and \> 75, pregnancy, splanchnic venous thrombosis, HCC, HE, significant cardiopulmonary disease, uncontrolled diabetes, hypertension, intrinsic renal disease, peripheral vascular disease. * Sample Size with justification: This is a pilot study where a total of 60 patients will be enrolled - 30 each in the two groups. * Intervention: HVPG will be done in these patients at baseline and then after 3 hours of 10 mg of midodrine tablets. Monitoring and assessment: Various parameters will be assessed during the procedure before and after 3 hours of midodrine such as HVPG (WHVP - FHVP), SVR, heart rate, cardiac output, cardiac index, Blood pressure (systolic, diastolic and mean), SpO2. \- Statistical Analysis: Continuous data will be represented by mean ± SD or median ± IQR. Categorical data will be represented by n = frequency (%). Categorical data will be analyzed by Chi square test or Fisher exact test as appropriate. Continuous data will be compared by using student t test or Mann Whitney test (when applicable). The change in HVPG will be analyzed by using paired t test or Wilcoxon signed rank test. The % change in the individual group will be compared to see the significance between the groups. The significance will be seen at 5%. * Adverse Effects: same as for HVPG (mild pain / hematoma at the puncture site, transient arrhythmias). Midodrine has got good safety profile and is used in patients of advanced chronic liver disease. * Stopping Rule of study: nil Expected outcome of the project: If result shows that HVPG is decreased by midodrine, then it can be used in place of beta blockers when they are contraindicated or have the potential of causing adverse effects.