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Objectives: The objective of this study was to evaluate the causes of decreased resistive index with graft dysfunction and to evaluate the outcome of different interventions performed in such cases. Materials and Methods: It is a retrospective analysis which was done at Sindh Institute of Urology and Transplantation, Karachi, Pakistan, between 2005 and 2015. Case notes of all patients who had renal transplantation in this time period were analyzed for demographic data, angiographic findings and serum creatinine values at the time of decreased resistive index. The type of management which was off ered was also recorded. Finally, the graft function and postoperative resistive indices were analyzed. Data were entered and analyzed in SPSS version 10.0. Results: A total of 53 patients were included in this study. The majority of these patients (41: 77.4%) were male (Figure 1) with mean age of 27.4±9.6 years. Causes of decreased resistive index included; graft under tension, 34 (64.15%); arterial kinking, 9 (16.98%); arterial stenosis, 8 (15.09%) and fungal arteritis, 2(3.77%). The majority of the patients were managed by re-exploration and minimizing the tension of graft by placing it in subcutaneous space. Two patients underwent graft nephrectomy because of fungal infection. Mean serum creatinine values in pre- and post-operative periods were 1.66±0.78 mg/dl and 1.32±0.79 mg/dl, respectively. Conclusions: Decreased resistive index on color Doppler imaging in early post-operative period warrants prompt surgical intervention. [ABSTRACT FROM AUTHOR]