الفهرس 
Acknowledgment
List of figuresOnly 14 pages are availabe for public view
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Abstract
The current study found no significant correlations with albumin, CRP, liver enzymes, HbA1c, and collagen IV. Also, it was noticed that level of serum ferritin showed no significant difference in different levels of hemochromatosis according to TSAT level in HCV –negative HD patients. Advances in serological and radiological tests such as blood marker panels, transient elastography, and their combination can enable accurate assessment and reduce the need for a liver biopsy. Although an impressive number of biochemical tests are now becoming available, establishment of a rationale for their clinical use is difficult (223).Serum concentrations of collagen, especially type IV, have proved to be a useful, noninvasive measure of the activity of this pathway at a single time point and have been shown to reflect prognosis and response to treatment for a variety of chronic liver diseases (224). In our study we measured serum collagen IV in HCV -negativ HD patients to asses degree of hepatic fibrosis. Collagen-IV at cut off point > 2959 pg/ml had 40% sensitivity and 90% specificity for detection of advanced fibrosis with overall accuracy was 67.5%.In case of patients with negative HCV Ab with normal T-SAT, serum Collagen-IV at cut off point > 2978 had 36% sensitivity and 94% specificity for detection of advanced fibrosis with overall accuracy was 49.4%.
In case of patients with negative HCV Ab with high T-SAT, serum Collagen-IV at cut off point > 2849 pg/ml had 46% sensitivity and 86% specificity for detection of advanced fibrosis with overall accuracy was 60.2%.
Another study by Karsdal et al., (2019)(225) for assessment of liver fibrosis progression and regression by a serological collagen turnover profile postulated that collagen type VI remodeling was increased in patients who were progressing and qualified as a progression marker, and the combination with PRO-C3 may likely indicate accelerated turnover of interstitial collagen during fibrogenesis. Here we found that a cut-off of serum iron of > 157 mcg/dl to be the best at detection of liver injury with 84% sensitivity, 62% specificity, and with overall accuracy of 72.1% (AUC= 0.79, p< 0.001). Also, we deem a cut-off of T-SAT > 80 % to be the best at detection of liver injury with 68% sensitivity, 73.3% specificity, and with overall accuracy of 71% (AUC= 0.70, p< 0.001). In the current study we found that predictors for advanced fibrosis injury hepatitis C- negative hemodialysis patients with hyperferrtinaemia was high serum iron (odd’s ratio=4.74, 95%CI= 1.10-6.56, P< 0.001) and high T-SAT (odd’s ratio=3.39, 95%CI= 1.24-5.56, P= 0.03). Secondary iron overload in patients with chronic kidney disease (CKD) due to iatrogenic iron replacement is an emerging medical challenge. There are limited options to manage secondary iron overload in patients with CKD as most iron chelators are contraindicated due to low creatinine clearance. In addition to that, accuracy of serum ferritin in monitoring is questionable since it is affected by different variables including inflammation and liver disease. The current study found that magnetic resosnce image could be used as non-invasive tool for assessment of hemochromatosis in patients with ESRD on regular hemodialysis. Also, we found that the best predictors for advanced liver fibrosis in HCV negative hemodialysis patients were serum iron and transferrin saturation. It’s recommended to: Conduct such studies on large scale of patients to confirm the findings. Conduct further studies to validate the utility of other non-invasive markers of hepatic fibrosis as APRI and FIB-4 in HCV negative hemodialysis patients particular in presence of hyperferrtinaemia. Assessment of the patients with raised serum ferritin (> 1700 mcg/dl) with MRI to evaluate the degree of hemochromatosis. Judicious use of iron preparation in patients with ESRD on RRT guided by serum iron and TSAT. Individualization of treatment of renal anemia in patients with ESRD. Further follow up of those patients with severe degree of hemochromatosis and advanced degree of hepatic fibrosis. Iron overload is an increasingly recognized clinical situation among hemodialysis patients. Recent studies using quantitative MRI to estimate liver iron stores have suggested a strong link between the IV iron dose and the risk of iron overload in dialysis patients, and have challenged the reliability of currently accepted iron biomarker cutoff values and clinical guidelines, especially regarding recommended iron doses. Iron-overload toxicity is now one of the most controversial topics in the management of anemia in dialysis patients. It can lead serious cardiovascular complications. Also, iron deposit may occur in many other organs as liver, pancrease and different glands. This will eventually deteriorate the outcome of those patients and increase morbidity and mortality. The current study was conducted over one year duration between 2019 and 2020. It aimed to assess effect of possible iron overload on liver of patients with end stage renal disease (ESRD) on regular hemodialysis. Eighty patients with ESRD were enrolled in the study (55 patients were HCV seronegative and 25 patients were HCV seropositive). It was found that serum iron, ferritin and transferrin saturation were significantly higher among HCV seronegative hemodialysis patients. Also, majority of HCV negative hemodialysis patients had severe degree of hemochromatosis based on assessment with magnetic resonance image while majority of HCV positive hemodialysis patients had mild degree of hemochromatosis. Subgrouping of HCV negative hemodialysis patients based on transferrin saturation; we found that majority of those patients with high transferrin saturation had severe degree of hemochromatosis while mild degree was observed among those with low transferrin saturation. It was also, found as direct correlation between serum ferritin and degree of hemochromatosis by MRI where degree of hemochromatosis was advanced as the level of ferritin increased. In case of HCV-negative hemodialysis patients, we found a cut-off of serum ferritin of > 1700 mcg/dl to be the best at detection of advanced hemochromatosis with 92% sensitivity, 40% specificity, and with overall accuracy of 67%.Based on the current study, predictors for advanced liver fibrosis in hepatitis C- negative hemodialysis patients with hyperferrtinaemia was high serum transferrin (at cut off point > 80% with overall accuracy was 71%) and high serum iron (at cut off point > 157 mcg/dl with overall accuracy of 72.1%).