الفهرس 
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Abstract
Renal failure is a frequent complication of patients with liver cirrhosis which is associated with increased mortality and morbidity, Diabetes is highly prevalent in the cirrhotic population and is associated with an increased risk of complications, such as hepatic encephalopathy and hepatocellular carcinoma, ascites, renal dysfunction, and bacterial infections. Diabetes is an independent prognostic factor for a higher risk of mortality in patients with cirrhosis, type 2 diabetes mellitus (T2DM) accelerates liver fibrosis and inflammation, resulting in more severe liver failure .
Once the diagnosis of DM is confirmed, efforts should be made to incorporate the management of DM into the patient’s overall treatment plan, with aims to slow the progression of CLD and to reduce the risk of liver failure-related complications.
The aim of this study to study renovascular resistance in diabetic and cirrhotic patients by using renal Doppler indices (RI and PI )
Methods
This study included 90 patients (type 2 DM and post-viral hepatitis cirrhotic patients ) they divided into three groups :- (C – group 30 patients) cirrhotic non diabetic group , (D –group30 patients ) diabetic non cirrhotic group and (CD- group 30 patients ) cirrhotic patients with type 2 diabetes mellitus. All patients underwent full clinical examination, routine laboratory tests and renal Doppler ultrasonography.
Results
The resistnce index (RIs) were increased in the patients of the CD-group and D-group compared with those of the C-group (0.75±0.03 vs 072±0.06 vs 0.69±0.04 ) (p- value0.01) . similarly the pulstality index( PIs) were significantly higher in the CD-group and D-group compared with the C-group (1.55±0.04 vs. 1.47±0.09 vs 1.45±0.11.) (p- value 0.01) .
The resistnce index and pulstality index (RI &PI) values were significantly increased during the advanced stages of liver cirrhosis (Child–Pugh Classes B and C) compared with the early stage (Child–Pugh Class A), and are irrespective of whether the patients have diabetes.
Our results indicate that the presence of diabetes may contribute to increases in the renal Doppler indices in patients with cirrhosis (RI & PI 0.75±0.03& 1.55±0.04 in the CD- group) vs (RI & PI 0.69±0.04 &1.45±0.11 in the C- group) independent of the severity of liver disease, as evaluated by the Child–Pugh scoring system. The increased levels of microalbuminuria that were observed in our cirrhotic patients with diabetes(32.73±10.70) compared to cirrhotic patients (9.98±5.60)
In this study statistically significant positive correlation was found between renal duplex indices represented by RI and HbA1c and albumin /creatinine ratio(r= 0.44, p-value0.02 and r =0.40 , p- value 0.007) respectively and PI with age ,HbA1cand albumin / creatinine ratio(r=0.32 p-value 0.03,r=0.38 p- value 0.04and r=0.42 p- value 0.004). In our study Univariate regression analysis revealed that the PI was significantly associated) with age, HbA1c and albumin /creatinine ratio (r = 0.004with p =0.03and r =0.03 with p =0.04 and r =0.003 with p =0.004 respectively ) and RI was significantly associated with HbA1c and INR (r = 0.02with p =0.02and r =0.04 with p =0.03 respectively) .
An additional finding of our study is the presence of arterial hypertension and macrovascular complications in the cirrhotic patients with diabetes. We find that in the CD Group, 16 (53.33%) of the patients have arterial hypertension, 2 (6.6%) had ishemic heart disease,and in the (D-droup) 12 (40%) of patients have arterial hypertension and 8(26.67%) of patients have ischemic heart disease and in the (C- group) 4 (12.33%) patients have hypertension.
Conclusion:
This study shown that diabetes has significant detrimental effects on the renal health of patients with liver cirrhosis and that it aggravates renal
vasoconstriction. Diabetes may represent an additional precipitating factor of renal failure in cirrhosis.
An understanding of the role of diabetes and the mechanisms that underlie it may improve our ability to evaluate the prognosis of patients with cirrhosis and assist in therapeutic decisions
Once the diagnosis of DM is confirmed, efforts should be made to incorporate the management of DM into the patient’s overall treatment plan, with aims to slow the progression of chronic liver disease CLD and to reduce the risk of liver failure-related complications.
Renal Doppler ultrasound examination is a safe and reproducible technique for evaluating arterial blood flow, and it has been extensively validated as an indicator of renal vasoconstriction in various pathologic conditions, including obstructive or interstitial nephropathy, acute tubular necrosis, latent or full-blown hepatorenal syndrome, and cirrhosis with ascites.
The presence of renal dysfunction is often missed in patients with cirrhosis. Because of a reduction in muscle mass in these patients, serum creatinine may be within the normal range, even with a very low GFR. The use of blood urea nitrogen (BUN) concentration as a measure of renal function is even less reliable, because BUN levels can be affected by the presence of gastrointestinal bleeding or by the amount of protein in the diet, and here comes the major role of renal duplex Doppler assessment of renovascular impedance to pick that sector of patients at high risk of developing renal failure and anticipating renal dysfunction
Recommendation:
Based on the results of our study. We recommend using renal Doppler ultrasonography to cirrhotic patients with diabetes with normal kidney function for early detection of renal affection and for proper and early management especially renal Doppler is non-invasive technique.
The present study has some limitations like relatively small sample size so, Further studies with larger sample size are needed to assess the value of renal Doppler ultrasonography indices as predictors of renovascular resistance in cirrhotic patients with diabetes.