Background: Since MAFLD and CKD, especially diabetic nephropathy, are two very prevalent entities with important consequences for cardiovascular health. They share common and complex risk factors and pathophysiological pathways, and also MAFLD can precede CKD. Moreover, when they coexist, their deleterious effects are potentiated, so It‘s important to fol-low up kidney functions in fatty liver disease and also to follow up fatty liver in renal patients even if reach End stage. Aim of Study: Detection of degree of risk of liver fibrosis in ESRD on RHD who complicated with metabolic syndrome and fatty liver to prevent progression of this fibrosis to cirrhosis and decrease incidence of Decompensated liver disease and HCC in this type of patients. Patients and Methods: A group of 50 ESRD patients who are on regular hemodialysis (3 times / week) will be enrolled to the study, study will be performed in the Renal dialysis unit, Souad Kafafi Teaching Hospital, Faculty of Medicine, MUST University. The study will span a period of six months, involv-ing a detailed analysis of patient data to achieve the research objectives. Results: An overwhelming majority, 94% (47 patients), showed that they had fatty liver. The liver enzymes AST (22.43±10.86) and ALT (19.71±11.0) show relatively low aver-ages with ranges extending from 6 to 48 and 6 to 53, respec-tively, suggesting mild liver enzyme elevation in some cases but mostly within normal limits. Albumin levels have a mean of 3.18g/dL (±0.58), with a range from 1.9 to 4.6, reflecting generally low and low normal levels in most patients. The FIB-4 score, a non-invasive index used to assess liver fibrosis, for a cohort of patients. The mean FIB-4 score is 1.25 (±0.56), with a range from 0.44 to 2.72, suggesting varying degrees of fibrosis risk among the patients. Notably, 68% (34 patients) are classi-fied as low risk, while 32% (16 patients) fall into the intermedi-ate risk category. Importantly, one patient is categorized as high risk. The mean NAFLD score is –0.37±1.29, with a wide range from –3.08 to 1.89, reflecting varying degrees of liver fibrosis severity. Notably, 22% of patients fall into the F0F2 category, indicating no significant fibrosis. A majority, 60%, fall into the “Undetermined" range, suggesting that further diagnostic eval-uation, such as a liver biopsy, might be necessary to assess their fibrosis status accurately. Meanwhile, 22% of patients exhibit significant fibrosis, categorized as F3-F4. Conclusion: The prevalence of NAFLD in diabetic patients on RHD was high. NAFLD can be diagnosed with ultrasonog-raphy. The FIB-4 score has demonstrated limited utility in this specific patient population, whereas the NAFLD Fibrosis Score (NFS) exhibits only a moderate capacity to predict advanced hepatic fibrosis. Despite its suboptimal diagnostic accuracy, the NFS may serve as a pragmatic alternative in clinical scenarios where advanced diagnostic modalities, such as transient elas-tography (TE) or magnetic resonance imaging (MRI), are either unavailable or inaccessible. This underscores the need for care-ful consideration of diagnostic tools in resource constrained settings to optimize patient management.