Tehran University Medical Journal

Background: Resistant hypertension is defined when the blood pressure remains elevated above the therapeutic target levels despite the use of three antihypertensive agents including calcium channel blocker (CCB), renin-angiotensin system (RAS) blocker and a diuretic. These drugs should be used at maximally tolerated doses and white coat effect and non-adherence should also be excluded. In this article, by describing a case of resistant hypertension, we discuss a diagnostic and therapeutic approach to resistant hypertension.
Case Presentation: A 59 years old man, known case of diabetic nephropathy with a serum creatinine level of 1.2 mg/dL and proteinuria of about 3300 mg in 24 hours referred to Hypertension Clinic of Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, for evaluation of resistant hypertension. The patient was under treatment by losar-H, diltiazem, and furosemide, which are not appropriate combinations of antihypertensive agents. The ambulatory blood pressure monitoring (ABPM) of the patient revealed daytime and nighttime hypertension and also the non-dipping status of blood pressure. Dihydropyridine CCB was prescribed in combination with RAS blocker (Exforge 50 mg/ 160 mg) and the diuretic was changed to thiazide-like agents. In the next step, spironolactone and carvedilol were added for better control of blood pressure. The patient referred to the sleep clinic for polysomnography and evaluation of obstructive sleep apnea. Following three months prescription of these medications, ABPM revealed relatively appropriate control of blood pressure, so the average 24-hour blood pressure decreased from 157/91 mm Hg to 136/83 mm Hg.
Conclusion: The complications and mortality of hypertension would be increased dramatically in patients with resistant hypertension. So, an appropriate diagnostic and therapeutic approaches should be considered for these patients. Choosing appropriate diuretic agents would be important in the management of resistant hypertension.

Background: Pentoxifylline, a valuable medication with promising clinical characteristics and considerable profile of safety is used in many conditions namely chronic kidney diseases (CKD). However, the decision to prescribe pentoxifylline for anemia in CKD should be based on evidence accrued from randomized controlled trials (RCTs). Yet, substantial heterogeneity exists in studies performed to evaluate pentoxifylline therapy, particularly in relation to classification of patients, the different quality and research design, sample size, baseline parameters, clinical outcome measures, and definition of endpoints and clinically meaningful improvements. As a result, assessment of pentoxifylline in treating anemia of CKD by conducting a systematic review and meta-analysis of the published relevant clinical studies seems rational and promising.
Methods: The present systematic review was done in accordance with the PRISMA guideline for systematic reviews and meta-analysis. Peer-reviewed RCTs with at least four weeks of follow-up were including in the meta-analysis. Online databases (PubMed/Medline, ISI Web of Science, Embase, and Scopus) were searched to December 2017 using selected MeSH terms related to the studied topic. Data was extracted independently by two reviewers using a standard form and then cross-checked. Statistical analyses were carrying out with Stata Software, version 7.0 (Stata Corp., College Station, TX, USA). P value of less than 0.05 was considered statistically significant. Data are presented as standard mean difference (SMD) and confidence interval (CI) 95%.

Background: The Electronic Health Record contains personalized health care information. Several factors affect the quality of SEPAS (Iranian electronic health record) data, disregarding the types of hospital information system set-up in hospitals. The purpose of this study was to investigate users' views on the factors affecting the data quality of Iranian Electronic Health Record (SEPAS) in hospitals affiliated to Mashhad University of Medical Sciences.
Methods: This descriptive cross-sectional study was conducted in 2018. In this study, the views of supervisors of the SEPAS system, HIS chief officers, and head of health information technology departments of hospitals were evaluated through a valid and reliable researcher-made questionnaire. Content validity ratio and content validity index of the questionnaire were validated as 0.82 and 0.94, respectively. Furthermore, the internal questionnaire reliability was affirmed by Cronbach's alpha of 0.96. Data analysis was conducted using descriptive statistics in the SPSS v.16 software.

Background: Lung cancer is a disease with high mortality rate that conventional drug treatments have not been successful in controlling it. The activity of iron chelators in various studies has been considered by scientists as a new treatment strategy. The primary objective of this study was to synthesize a novel Fe3O4 thiosemicarbazone complex and investigate its anti-proliferative activity against A549 cells of lung cancer.
Methods: This experimental study was carried out in Islamic Azad University of Rasht Branch, from September of 2018 to September 2019. First thiosemicarbazone (PTSC) was synthesized by the method of the condensation reaction of amine and aldehyde groups. Also, the Fe3O4 nanoparticulates were synthesized using the co-precipitation method in the presence of glutamic acid. Then, Fe3O4@Glu complex functionalized with bio-reactive PTSC moiety. Besides, morphological characteristics of Fe3O4@Glu/PTSC complex were determined by scanning electron microscope (SEM) images. The cell viability was detected in 62.5, 125, 250, 500, and 1000 µg/ml for treated cells with Fe3O4@Glu/PTSC complex via MTT assay. Changes of NDRG1 gene expression the level in treated cells were investigated via qRT-PCR analysis. Therefore, total RNA was extracted after culturing the cells and cDNA of NDRG1 and GAPDH genes as the study and control gene was obtained, respectively. Ultimately, the level of NDRG1 gene expression was compared with level of GAPDH mRNA expression via the 2^{– ΔΔCt} method.

Background: Studies have shown that 75% of men and 35% of women over the age of 10 have hamstring tightness. Hamstring tightness is one of the major causes of hamstring injury and loss of function. Dry needling which is a common intervention used by physiotherapists for the treatment of common various conditions can improve hamstring flexibility in less time than other interventions. So, the present study aimed to investigate the effect of dry needling on flexibility and electrophysiological indices in healthy men with hamstring tightness.
Methods: In this two-way blind clinical trial with a control group, which was performed from November 2018 to February 2019 in the laboratory of the Faculty of Rehabilitation of Tehran University of Medical Sciences, 30 healthy men with hamstring tightness were randomly divided into two groups of dry needling (n=15) and sham needle (n=15). In both groups, dry needling and sham needle, three points of hamstring muscle were needled, each point for one minute during a single session. Outcome measures included flexibility based on passive knee extension test, H-reflex latency, and motor neuron excitability, which were measured three times: before the intervention, immediately after the intervention, and one week after the intervention.
Results: The results revealed that the mean of passive knee extension test (P=0.54), the mean delay time of H-reflex (P=0.84) and the mean of excitability of the motor neuron (P=0.41) didn’t have significant different between two groups after intervention.
Conclusion: The findings of this study showed that dry needling had no effect on hamstring flexibility and electrophysiological indices recorded in the soleus muscle of healthy individuals with hamstring tightness.

Background: Intravenous (IV) injection of drugs is one of the most common methods of drug prescription in hospitals, which is a complex, potentially hazardous and erroneous method; accordingly, it requires control methods to reduce the potential risks. This study focused on determining the frequency and types of different medication errors while preparing and administering mostly used IV drugs in three intensive care units (ICU) and one general department in AL-Zahra hospital, Isfahan, Iran.
Methods: This cross-sectional observational study was conducted for 6 months from September 2017 to March 2018. To determine the frequency of different medication errors, a quoting sampling method was applied to select and observe 400 cases of IV drug administrations. All nurses from any studied department were included in this study. Different stages of preparation and administration of the observed drugs were compared to an instructed checklist prepared by the clinical pharmacist.

Background: Common treatment for infertile couples is the use of controlled ovulation hyperstimulation (COH) with intrauterine inseminations (IUI). IUI is used in cases such as ovulatory dysfunction, cervical factor infertility, male subfertility, and unexplained infertility. In this study, we evaluated the relationship between IUI outcome and special causes of infertility.
Methods: This was a cross-sectional study and a sampling method was available in this study, from January 2014 to August 2016, 994 cycles in 803 infertile couples referred to Royan Research Institute in Tehran were analyzed. Inclusion criteria were: male factor infertility, combined causes, ovarian disease, and infertility of unknown cause. To evaluate pregnancy, 12-16 days after IUI, it was considered positive if pregnancy test followed by transvaginal ultrasound at week 4 after IUI were positive.
  Data were analyzed using SPSS software, version 20. T-test and chi-square were used to compare the case and control groups. Linear-by-linear test was also used to calculate the relationship between female age and clinical and multiple success rates. P<0.05 was considered significant for the results of these tests.

Background: Low-level lasers are used for various medical applications including wound healing and hair loss treatment. Cell Therapy using skin stem cells could be a novel approach to hair transplantation. However, there is no study on the effect of low-level laser on the hair follicle stem cells. So, in this study, we investigated the effect of low level laser irradiation on viability and ROS production in the hair follicle stem cells.
Methods: This study was performed in the cell culture laboratory of Medical Laser Research Center, Yara Institute in 2020 (June 2020 to February 2020). The hair follicle was isolated from the Safe Donor Area (SDA) using the 4mm punch method. In the laboratory, after separating the follicular units, the bulb region of each follicle was isolated via mechanical and enzymatic methods and cultured in FBS+F12-DMEM. Afterward, the stem cells were characterized via flow cytometry. The effect of low-level laser (685 nm) with different doses (1-20 J/cm²) was investigated on cell proliferation, viability and ROS production.

Background: SLC39A6 Protein (solute carrier family 39) or LIV-1 is a zinc transporter protein that is overexpressed in positive estrogen cancers such as breast cancer. The LIV-1 protein transfer zinc into the cytoplasm through the plasma membrane. Today it is known that just as a decrease in the concentration of zinc in the cell can cause cancer, an excessive increase in the concentration of zinc can also stimulate irregular cell division and caused cancer. Thus, inhibition of zinc transporter protein may play a role in preventing malignancies and metastasis. It can also be used as a diagnostic marker in the diagnosis of cancers in various laboratory methods. The present study was performed to prepare a polyclonal camel antibody for the detection of LIV-1 protein at the cell surface.
Methods: This study was started in the Pasture Institute of Iran in 2018 September and finished in February 2020. An expression construct containing the human LIV-1 gene was prepared and transferred to the E.coli BL21 by chemical (CaCl2) and heat shock method. The expression of the protein was induced by IPTG and then protein was purified by affinity (Ni-NTA) chromatography. After preparing recombinant protein one female camel was immunized, 6 times at two weeks intervals with Freund's adjuvant. After immunization, the isolated polyclonal antibody was evaluated by ELISA, western blotting and flow cytometry in the detection of LIV-1 protein.

Background: Normal vaginal delivery causes sexual dysfunction as well as urinary and fecal incontinence, which can threaten a person's quality of life. It is believed that pelvic floor muscle strength is the most important factor in improving sexual satisfaction and function and urinary control. Therefore, This study aimed to investigate the role of physiotherapy and pelvic floor exercises in reducing sexual dysfunction and incontinence in primiparous women.
Methods: This study was performed as a prospective randomized clinical trial on primiparous women who were referred to Al-Zahra and Shahid Beheshti educational hospitals in Isfahan between march 2019-Mars 2020. In this study, after obtaining ethics approval from the Medical Ethics Committee of Isfahan University of Medical Sciences, patients were divided into control (n=57) and intervention (n=57) groups. In the control group, no intervention was performed and only routine postpartum recommendations (multivitamin tablets and 500 mg calcium tablets once daily for two months) were prescribed. For the intervention group the pelvic floor physiotherapy was performed Sexual function and urinary and fecal incontinence were assessed in both groups at 8 and 16 weeks postpartum by completing two questionnaires.

Conclusion: it seems that simultaneous performance of physiotherapy (biofeedback) and pelvic floor exercises by strengthening the strength of the pelvic floor muscles increases sexual function as well as a relative improvement of pelvic floor irritation in the postpartum period.

Background: Anemia has a very high prevalence across the world. Microcytic anemia is the most common nutritional disorder and a major health problem in infants and children associated with inadequate growth and development. Diagnosing anemia at the birth can be difficult. Due to the fact that conditions such as thalassemia and iron deficiency are causative factors of microcytic anemia are prevalent in Iran, early diagnosing and treating these diseases can prevent excessive costs and further complications. Therefore, recognizing the practical factors with this complication is an effective step in controlling and preventing it. Therefore, the present study was performed to determine the prevalence of microcytic anemia in newborns in Baharloo Hospital in Tehran, Iran.
Methods: This cross-sectional study was performed on 210 infants, which were newly born on Baharloo Hospital from march2018 to march2019. 2.5 cc cord blood sample was extracted from each infant, and microcytic anemia were diagnosed according to factors such as Hb, MCV and others parameters.
Results: in this study, we demonstrated that there is a significant association between MCH and microcytic anemia. Our results showed that the rates of newborn infants with anemia disease (Hb<13ml/dl) were 14.3% and the rates of microcytic anemia were 9.5%. There were not any significant differences between mother's age, neonatal weight and height, type of parturition, pregnancy age and parental ratio with the incidence of microcytic anemia.

Background: Skin cancer is the most prevalent type of cancer and melanoma is the deadliest kind of skin cancer in the world. Due to enhanced induction of apoptosis and ROS levels, low-level lasers can be utilized to destroy skin cancer cells. Lasers are used to treat some skin lesions. Vitamin A is beneficial in the prevention and treatment of skin cancer. Vitamin A inhibits the pathway of cancer signals in the skin and suppresses tumor growth. In this study, the combined effect of low-level laser radiation (LLL) and vitamin A on cellular factors of skin melanoma cancer cells was investigated.
Methods: An in-vitro interventional laboratory study was performed in the cell culture laboratory of Medical Laser Research Center, Yara Institute in 2020-2021 (July 2020 to July 2021). First, A375 skin cancer cells were cultured in DMEM with 10% FBS. After preparation and culture of A375 cell lines, different concentrations of vitamin A (1, 5, 50, 100 μM) and LLL energy doses (1, 2, 5, 10 J/cm²) as treatments were done. Combination research of these treatments was performed to eliminate skin melanoma cancer cells. The rate of viability was determined using the MTT test, and the rate of apoptosis was determined using flow cytometry.

Results: No RBC was detected in microscopy. The majority of the leucocytes were lymphocytes with rare accompanying platelets. The radiolabeling efficiency of the procedure was higher than 40%. The viability test indicated more than 80% of viable cells. The radiochemical purity of the final product was more than 95%. Two to four hours after injection, low background images were acquired. The liver and spleen were target organs with low-grade urinary, thyroid, and GI activity. Conclusion: Employing multi-stage centrifugation, Tc-HMPAO labeled leucocyte scan could be efficiently performed.

Background: Congenital heart defects (CHD) are the most common type of birth defects. The main screening tests used to identify babies with congenital heart defects include prenatal echocardiography and postnatal clinical assessment. Routine pulse oximetry has been reported as an additional screening test that can potentially improve the early diagnosis of critical congenital heart disease (CCHD).
Methods: This study is a multi-stage evolutionary study that was conducted for 12 months from March 2021 to March 2022 at Pediatric Cardiovascular Research Center in Cardiovascular Institute, Isfahan, Iran. In the first phase, after identifying the topic and aims of the present study, questions were designed through the PICO method including (population, intervention, control, and outcomes). Then conducting systematic searches, the quality of all existing clinical guidelines (CG) of this field were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument and a committee consisting of pediatric cardiologists and neonatologists in the field. Next, based on the opinions of experts, the quality of 1 out of 6 clinical guidelines for early detection of critical congenital heart disease at birth by pulse oximetry was assessed as optimal. Finally, the clinical guidelines draft was evaluated using the Delphi method and the panel of experts. After expert panel meetings and consensus between members, the final version of the guideline for early detection of critical congenital heart diseases at birth by pulse oximetry was developed.

Results: In the present study, criteria of clinical practice regarding the stages of newborn screening by pulse oximetry at birth were determined based on the evidence and health conditions and were presented in twenty-eight recommendations and six sections. The final recommendations were presented in the results section. Conclusion: The finding of the present study showed that physicians, nurses, and midwives can apply the recommendations of this clinical guideline for the early detection and referral of neonates with critical congenital heart disease.

Background: The training and education of competent and qualified surgeons have been one of the challenges of the surgical profession. The concept of surgical competence has been affected widely due to a series of developments in the new disease emergence, various surgical techniques and the introduction of advanced tools and equipment into the operating. The development of surgical competence and achieving this goal requires accurate identification and analysis of the dimensions of competence. This study was done to explain the concept of surgical competence using the 8-step Walker and Avant approach.
Methods: This study is a qualitative study that was conducted from May- October 2016 at Shahid Beheshti University of Medical Sciences. The present study is a qualitative and conceptual analysis study, which is done with Walker&Avant's eight-step approach to determine the defining characteristics of the concept of surgical competence. A systematic search was conducted between 1990 and 2020 by keywords search such as surgery, surgical, operation OR laparoscopy AND competence competency development competency proficient, proficiency, expertise, clinical, in the database like Google Scholar, PubMed, SID, Magiran, Scopus, Web of Science. Twenty articles were included in the study based on inclusion and exclusion criteria. Moreover, the defining features of the concept were extracted from it.

Results: Based on the results of this study, the concept of surgical competence was defined and the four dimensions of elements, goals, components and the process of developing surgical competence were identified. Then, by clarifying the characteristics of surgical competence, a model of surgical competence development was drawn. Surgical competence development depends on the acquisition of specialized knowledge and numerous skills that are acquired through experience and deliberated practice under the supervision of others in the surgical community of practice and over time. Conclusion: Surgical competence is a set of observable and measurable skills that allows a surgeon to manage the surgical process independently pbt while maintaining the patient's safety. It includes specialized knowledge, communication skills, cognitive and technical skills, and basic surgical skills.

Background: The prevalence of emerging and re-emerging diseases has made the need for basic preparations for all health care organizations more crucial. Strengthening preparedness and formulating crisis strategies will have a great impact on reducing casualties. Given the importance of preparing hospitals to deal with such an outbreak and reduce the resulting mortality, the present study was conducted to assess their readiness against Covid-19.
Methods: The present study is a quantitative and descriptive cross-sectional research conducted from October to March 2019. Data collection used the standard checklists prepared by the European Center for the Prevention and Control of Coronavirus and the Centers for Disease Control and Prevention, consisting of eight domains and 21 components. The minimum score that each hospital could get in this checklist was 143 and the maximum was 429. The sampling method in the present study was a census, and nine reference hospitals for Corona were included in the study. All hospitals’ directors, managers, quality officers and crisis secretaries and others related to hospital readiness during Covid-19 were recruited by the census.

Results: On average, the hospitals scored 391 out of 429, indicating a fairly "high readiness" in dealing with Covid-19. The highest score obtained by the hospitals was 425 and the lowest score was 349. In terms of preparation areas, the hospitals’ readiness was higher than 80% in all areas. The highest readiness of hospitals was in the fifth  domain, i.e. Hand hygiene, personal protective equipment and hospital waste management. The 7th domain namely, patient placement and relocation, and patient visitor access was of the lowest preparation. Conclusion: The hospitals were of fairly appropriate readiness to deal with Covid-19. This level of preparedness, despite being desirable, might not reflect the real capacity of hospitals to deal with this disease. Regular evaluation of the Covid referral hospitals could help make these hospitals more prepared. Also, the experiences of hospitals that were more prepared should be used to improve the condition of other hospitals.

Background: The purpose of this article was comparing the clinical effectiveness of low-level laser therapy (LLLT) in reducing relapse.
Methods: In this clinical trial study 14 patients (11 females and three males) who were under non-extraction treatment (MBT 022 slot) and at the finishing stage of orthodontic treatment at Orthodontics Department of Kerman Dental Faculty from April 2016 to June 2017 participated. Treatment time was two year and the patients at the finishing stage of orthodontic treatment were divided into two groups (RCT code IRCT2017053034061N1). Group 1 (study) were treated with a low-level Gallium aluminum-arsenide diode laser and group 2: control. The exclusion criteria involved patients who consumed medicine that interrupted bone metabolism and those with conditions for which laser therapy could be contraindicated. The laser apparatus emitted a wavelength of 810 nm about 50 seconds and operated with maximum power of 200 MW in continuous wave mode (200 mW, 50 seconds radiation to mesiolingual, mesiobuccal, distolingual and distobuccal surfaces, 35.7 J/cm²). An alginate impression was made from maxillary arch for all patients immediately, four, five and six months after removing the orthodontic archwire and braces and study casts were prepared. The little irregularity index of anterior maxillary arch was measured on the dental casts, with a 0.01 mm precision digital caliper. Intergroup comparisons were performed with Student's t-test and repeated measure ANOVA was perform to compare measurements among groups in different times. The significance level was considered at P<0.05.

Results: There was significant difference among the irregularity index at five and six months after orthodontic treatment between two groups (P<0.05). In the control group except between five and six months after treatment, there was significant difference in irregularity index. The relapse was higher immediately and after four months in the laser group compared to other sequences (P=0.0001). Conclusion: Sample showed that Low-level laser therapy (LLLT) is a non invasive method for reducing relapse after orthodontic treatment.

Background: Although cervical cancer in adult women with early diagnostic tests has better treatment ability and disease management, precise and fast diagnosis of any signs of cervical intraepithelial neoplasia (CIN) I-III and high-risk dysplasia is vital. If any precancerous/abnormal suspicious cells are not detected in the routine diagnostic process (pathology), they cannot be treated before the lesion turns into cervical cancer, consequently help increasing the patient’s survival rate.
Methods: In this clinical study, the efficiency and diagnostic accuracy of the electrochemical measuring device of glycolysis metabolism in cancer cells (HEA: Hypoxia electrochemical assay) on in-vitro human fresh cervical samples were studied. The samples were prepared from 40 candidates of conization through a history of abnormal cell presentation in their pap smear results. The study was conducted at the Gynecology Department, Yas Hospital, Tehran University of Medical Sciences, and assistant hospitals from August 2018 to June 2021. Patients provided consent according to an ethically approved protocol. A CIN-based scoring of HEA responses was proposed by considering the pathology reports of HEA-tested regions.

Results: The diagnostic calibration of the sensor was achieved by comparing the ROS/H2O2 electrochemical current related to cell glycolysis with the presence of cancer cells in the samples' histology. The current diagnostic threshold obtained by the sensor to differentiate cancerous areas from others showed an accuracy of 95% (P<0.0001). The accuracy and sensitivity of the sensor were 95% and 100%, respectively. Therefore, a matched clinical diagnostic classification between the pathological results of tested tissues and the sensor's electrochemical ROS/H2O2 response was proposed based on CIN categorization.

Background: Febrile seizures (FS) are the most common cause of seizure in children. In order to prevent FS and their recurrence, the recognition of the related factors to recurrence of FS is important. According to the high prevalence of FS and iron deficiency anemia (IDA) in children and that IDA is a possible risk factor for FS, as well as controversies in previous studies in this field, in this study, the relationship between iron deficiency anemia and FS in children was investigated.
Methods: This is a case-control study that investigates the relationship between febrile seizures with anemia in 150 patients aged six months to five years with fever who were admitted to Imam Sajjad Yasouj Hospital, from April to August of 2014. In this study, 75 patients with febrile seizures (case group) and 75 febrile patients without seizures (control group) were compared. Cause of fever (urinary infection, gastrointestinal infections, upper respiratory infection, lower respiratory infection and other causes), Information about blood cell count (white blood cell (WBC) and red blood cell (RBC), hemoglobin (HB), mean red blood cell volume (MCV) and serum ferritin level in patients with hemoglobin below 11 were recorded.

Results: The mean age of the study population was 21.4 14 months. 34.7% of the study population were girls and 65.3% were boys. In this study, 10.7% of the cases and 8% of the controls had IDA. Although the prevalence of IDA was higher in the FS group, this difference was not significant (P=0.58). Also, HB and MCV were not significantly different in the two groups (P=0.49, P=0.69). In addition, the mean serum ferritin level in the FS group with anemia and the FS group with anemia did not show a statistically significant difference (P=0.94). Conclusion: According to the result of this study, IDA is not a risk factor for seizures in febrile children.

Background: Adequacy of dialysis is a very important issue in dialysis patients, so comparing the adequacy of dialysis in different dialysis methods is very important. Therefore, due to the fact that the number of people undergoing dialysis  through fistulas and catheters varies in different centers, and depending on different centers, there is a possibility of decreasing or increasing the adequacy of dialysis, so we decided to do this comparison in Arak support center.
Methods: In this analytical-cross-sectional study, the dialysis patients of Hami Arak Center from April 2019 to September 2019 were divided into two groups (the first group with permanent catheter, the second group with arteriovenous fistula) based on vascular access. The both groups were matched in terms of age, sex, weight, pump speed, filter size and also the duration of dialysis. All patients were dialyzed with the same type of dialysis machine, and the duration of hemodialysis for all samples was 4 hours in each session. To confirm the reliability of the device, it was calibrated before each use and the same setting was used for all samples. The blood samples were taken from the arterial route before dialysis and starting the dilution with heparin or normal saline. Statistical models of dialysis adequacy of patients in two groups were measured using the Kt/V criterion, SPSS and AMOS data analysis was performed.

Results: In the analysis of covariance of BUN before dialysis, there is a statistically significant difference in the studied groups (P<0.05), also in the UF and URR variables, dialysis time and the number of times of dialysis in three consecutive repetitions, there is a statistically significant difference in the studied groups. (dime fistula and catheter) are not present (P<0.05). Conclusion: In this study, during repeated repetitions, 22% of the dialysis adequacy in the two groups did not have good adequacy, and 78% of the patients in the two groups had appropriate dialysis adequacy.