Kidney perfusion can be acutely compromised by many factors including reduced systemic blood pressure and elevated intra-abdominal pressure. We present a case of near complete absence of kidney perfusion in a 57-year-old man with heart failure and new onset ascites. The renal perfusion defect was directly detected by Doppler ultrasonography. Immediate decompression with large-volume paracentesis restored the kidney perfusion and kidney function. This case illustrates that renal ultrasonography with Doppler flow analysis in appropriate settings can serve as an important adjunct in the diagnosis and treatment of acute oligoanuric kidney failure. Timely reversal of the perfusion defect can rescue kidney function.