# Clinical Effects of Primary Nursing on Diabetic Nephropathy Patients Undergoing Hemodialysis and Its Impact on the Inflammatory Responses

Authors: Yujuan Guo; Qi Song; Yuhong Cui; Caihong Wang
Journal: Evidence-Based Complementary and Alternative Medicine
 (2022)

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## Abstract

Objective. To assess the clinical effects of primary nursing on diabetic nephropathy patients undergoing hemodialysis and its impact on inflammatory responses. Methods. Between July 2019 and April 2021, 80 patients with diabetic nephropathy who underwent hemodialysis in our institution were recruited and assigned at a ratio of 1 : 1 to receive either routine nursing (routine group) or primary nursing (primary group). The outcome measures included nursing outcomes, inflammatory factor levels, and psychological status. Results. Primary nursing resulted in lower levels of blood creatinine, fasting glucose, urea nitrogen, and proteinuria versus routine nursing (P<0.05). Patients receiving primary nursing showed significantly lower levels of interleukin (IL)-6, high-sensitivity C-reactive protein (hs-CRP), and tumor necrosis factor-alpha (TNF-α) versus those given routine nursing (P<0.05). The patients in the primary group had significantly lower scores on the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) versus those in the routine group (P<0.05). Conclusion. Primary nursing improves the renal function of diabetic nephropathy patients undergoing hemodialysis, reduces the inflammatory response, and eliminates their negative emotions, which shows great potential for clinical application.


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## Body

## 1. Introduction

In recent years, with improvements in people’s living standards, the incidence of diabetes mellitus has been on the rise [1]. Diabetic nephropathy is one of the common comorbidities of diabetes mellitus, and its incidence has also been increasing [2]. The main cause of diabetic nephropathy is the untimely and ineffective control of diabetes. Chronic hyperglycemia in patients leads to sustained damage to the renal vasculature due to blood pressure, which results in blood filtration overload in the kidneys and thus nephropathy [3]. The loss of metabolic function of the kidney over a certain level will progress to uremia, which requires dialysis treatment or kidney transplantation [4]. Diabetic nephropathy seriously compromises the life quality of patients. Hemodialysis can effectively improve the life quality of patients with diabetic nephropathy with a high safety profile; however, patients after hemodialysis treatment are predisposed to various complications, which seriously impair their physiological and psychological health and even threaten their life safety in serious cases [5]. A large body of clinical research has demonstrated the importance of active and effective nursing measures for diabetic nephropathy patients undergoing hemodialysis [6]. Although primary nursing care modality has been applied in numerous departments and diseases, the reports on diabetic nephropathy undergoing hemodialysis remain scant. In the present study, 80 patients with diabetic nephropathy undergoing hemodialysis in our institution were recruited to assess the clinical effects of primary nursing on these patients and its impact on inflammatory responses.


## 2. Materials and Methods

### 2.1. Baseline Data

Between July 2019 and April 2021, 80 patients with diabetic nephropathy who underwent hemodialysis in our institution were recruited and assigned at a ratio of 1 : 1 to either a routine group or a primary group. The baseline characteristics of the routine group (22 males, 18 females, mean age of 57.67 ± 3.48 years, mean disease duration of 14.21 ± 2.25 years, and mean dialysis time of 12.66 ± 3.59 months) were comparable with those of the primary group (23 males, 17 females, mean age of 57.28 ± 3.56 years, mean disease duration of 14.13 ± 2.31 years, and mean dialysis time of 12.87 ± 3.45 months) (P>0.05) (Table 1). This study has been reviewed and approved by the Medical Ethics Committee of the Qingdao Hospital of Traditional Chinese Medicine, No. 928797.Table 1
Comparison of baseline data (n (%)).
Routine group (n = 40)Primary group (n = 40)t or x2P valueGender0.0510.822Male2223Female1817Mean age57.67 ± 3.4857.28 ± 3.560.4950.622Mean disease duration14.21 ± 2.2514.13 ± 2.310.1570.876Mean dialysis time12.66 ± 3.5912.87 ± 3.45−0.2670.79


### 2.2. Inclusion and Exclusion Criteria

Inclusion criteria: patients without other vital organ disorders and without a history of psychiatric disorders and language and cognitive impairment were included in this study.Exclusion criteria: patients with a history of psychiatric disorders or recent use of antidepressants, with malignant tumors or hematological or immune system disorders, with congenital genetic disorders, who refused to participate in this study, with poor compliance, or who were unable to follow up were excluded from this study.


### 2.3. Methods

(1)
Patients in the routine group received routine care. The nursing staff recorded the patient’s nutrition, blood pressure, blood glucose, and relevant indicators, and informed the physicians promptly of the presence of adverse reactions in patients. The patients and their families were given health education about the disease and instructed to have a reasonable diet and appropriate exercise.(2)
Patients in the primary group received primary nursing. (1) Nursing staff educated patients about the knowledge and information of hypoglycemic drugs and taught them the correct method of insulin injection and preservation to ensure the correct and reasonable use of drugs. The patients were provided with health education about diabetic nephropathy to help them fully understand their disease [7]. (2) Hemodialysis is prone to organ function damage and even blindness in severe cases, which may lead to negative emotions such as anxiety and depression, resulting in the loss of patients’ confidence in treatment. Therefore, strengthened communication and timely psychological guidance to patients contributed to improving their psychological status and eliminating negative emotions, thereby ensuring the treatment effect. The patients were informed of the approach, process, necessity, and importance of hemodialysis, which facilitates the active cooperation of patients in hemodialysis treatment. (3) The nursing staff formulated an individualized and reasonable diet plan according to each patient’s condition and assessed the patient’s nutritional status by calculating the patient’s daily intake according to the patient’s urine volume. Insulin is usually used to control blood glucose in patients with diabetic nephropathy, but the compromised insulin catabolism and clearance in these patients predisposes them to exogenous insulin accumulation in the body. Thus, blood glucose requires close monitoring for adjustment of the insulin dosage. In the case of the signs of hypoglycemia, the patient was given food as soon as possible to avoid hypoglycemia [8]. (4) Nursing staff provided patients with targeted guidance on complication prevention, and patients with complications were treated with drugs with protective functions on renal function. The patient was given antihypertensive drugs as prescribed by the doctor if intractable hypertension occurred during hemodialysis. In the event of nausea, pallor, and cold sweats during dialysis, oxygen therapy was performed, the patient’s blood flow was reduced, and the patient’s ultrafiltration was discontinued. Plasma and hypertonic saline infusions were administered if necessary. (6) The patient’s puncture site was given medical care to avoid infection. Patients with long-term indwelling catheters were treated according to the requirements of aseptic practice.In addition, two groups were given traditional Chinese nursing. Patients with diabetic nephropathy suffer from dryness, heat, loss of energy, and deficiency of both Qi and Yin. The Guanyuan, Sanyinjiao, and Zusanli acupoints were massaged according to the doctor’s instructions to replenish the Qi and Yin and alleviate the symptoms of palpitations and irritability. For those with spleen and kidney yang deficiency, the ward was ventilated regularly to ensure sufficient sunlight, and hot compression was applied to the waist, knees, and abdomen. For abdominal distension, moxibustion was performed at the Pishu and bilateral Shenshu acupoints.


### 2.4. Outcome Measures

(1)
Nursing outcomes: the nursing outcomes included blood creatinine, fasting glucose, urea nitrogen, and proteinuria. Blood creatinine, urea nitrogen, and proteinuria levels were determined before and after the nursing using an immunoenzymatic assay with a fully automated biochemical analyzer. The fasting blood glucose level of the patients was determined using the Myriad BS-350 automatic biochemical analyzer with matching reagents of the analyzer. The lower the level of the above indexes, the better the nursing outcome.(2)
Inflammatory response indexes: the main indexes included interleukin (IL)-6, high-sensitivity C-reactive protein (hs-CRP), and tumor necrosis factor-alpha (TNF-α). 5 ml of fasting elbow venous blood was collected before and after the intervention, and the levels of IL-6, hs-CRP, and TNF-α were determined by ELISA. The specific operation was performed according to the instructions of the kit. The lower the level of the above-mentioned inflammatory response indexes, the better the nursing outcomes.(3)
Negative emotions: the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to assess the psychological status of the patients. SAS: <50 points indicate no anxiety, 50–59 points indicate mild anxiety, 60–69 points indicate moderate anxiety, and >70 points indicate severe anxiety. <53 points indicate no depression, 53–62 points indicate mild depression, 63–72 points indicate moderate depression and >73 points indicate severe depression. The lower the score, the better the psychological status of the patient.


### 2.5. Statistical Analysis

SPSS 22.0 was used for data analyses. The measurement data were expressed as (x¯ ± s) and processed using the independent sample t-test. The count data were expressed as the number of cases (rate) and analyzed using the chi-square test. Differences were considered statistically significant at P<0.05.


## 2.1. Baseline Data

Between July 2019 and April 2021, 80 patients with diabetic nephropathy who underwent hemodialysis in our institution were recruited and assigned at a ratio of 1 : 1 to either a routine group or a primary group. The baseline characteristics of the routine group (22 males, 18 females, mean age of 57.67 ± 3.48 years, mean disease duration of 14.21 ± 2.25 years, and mean dialysis time of 12.66 ± 3.59 months) were comparable with those of the primary group (23 males, 17 females, mean age of 57.28 ± 3.56 years, mean disease duration of 14.13 ± 2.31 years, and mean dialysis time of 12.87 ± 3.45 months) (P>0.05) (Table 1). This study has been reviewed and approved by the Medical Ethics Committee of the Qingdao Hospital of Traditional Chinese Medicine, No. 928797.Table 1
Comparison of baseline data (n (%)).
Routine group (n = 40)Primary group (n = 40)t or x2P valueGender0.0510.822Male2223Female1817Mean age57.67 ± 3.4857.28 ± 3.560.4950.622Mean disease duration14.21 ± 2.2514.13 ± 2.310.1570.876Mean dialysis time12.66 ± 3.5912.87 ± 3.45−0.2670.79


## 2.2. Inclusion and Exclusion Criteria

Inclusion criteria: patients without other vital organ disorders and without a history of psychiatric disorders and language and cognitive impairment were included in this study.Exclusion criteria: patients with a history of psychiatric disorders or recent use of antidepressants, with malignant tumors or hematological or immune system disorders, with congenital genetic disorders, who refused to participate in this study, with poor compliance, or who were unable to follow up were excluded from this study.


## 2.3. Methods

(1)
Patients in the routine group received routine care. The nursing staff recorded the patient’s nutrition, blood pressure, blood glucose, and relevant indicators, and informed the physicians promptly of the presence of adverse reactions in patients. The patients and their families were given health education about the disease and instructed to have a reasonable diet and appropriate exercise.(2)
Patients in the primary group received primary nursing. (1) Nursing staff educated patients about the knowledge and information of hypoglycemic drugs and taught them the correct method of insulin injection and preservation to ensure the correct and reasonable use of drugs. The patients were provided with health education about diabetic nephropathy to help them fully understand their disease [7]. (2) Hemodialysis is prone to organ function damage and even blindness in severe cases, which may lead to negative emotions such as anxiety and depression, resulting in the loss of patients’ confidence in treatment. Therefore, strengthened communication and timely psychological guidance to patients contributed to improving their psychological status and eliminating negative emotions, thereby ensuring the treatment effect. The patients were informed of the approach, process, necessity, and importance of hemodialysis, which facilitates the active cooperation of patients in hemodialysis treatment. (3) The nursing staff formulated an individualized and reasonable diet plan according to each patient’s condition and assessed the patient’s nutritional status by calculating the patient’s daily intake according to the patient’s urine volume. Insulin is usually used to control blood glucose in patients with diabetic nephropathy, but the compromised insulin catabolism and clearance in these patients predisposes them to exogenous insulin accumulation in the body. Thus, blood glucose requires close monitoring for adjustment of the insulin dosage. In the case of the signs of hypoglycemia, the patient was given food as soon as possible to avoid hypoglycemia [8]. (4) Nursing staff provided patients with targeted guidance on complication prevention, and patients with complications were treated with drugs with protective functions on renal function. The patient was given antihypertensive drugs as prescribed by the doctor if intractable hypertension occurred during hemodialysis. In the event of nausea, pallor, and cold sweats during dialysis, oxygen therapy was performed, the patient’s blood flow was reduced, and the patient’s ultrafiltration was discontinued. Plasma and hypertonic saline infusions were administered if necessary. (6) The patient’s puncture site was given medical care to avoid infection. Patients with long-term indwelling catheters were treated according to the requirements of aseptic practice.In addition, two groups were given traditional Chinese nursing. Patients with diabetic nephropathy suffer from dryness, heat, loss of energy, and deficiency of both Qi and Yin. The Guanyuan, Sanyinjiao, and Zusanli acupoints were massaged according to the doctor’s instructions to replenish the Qi and Yin and alleviate the symptoms of palpitations and irritability. For those with spleen and kidney yang deficiency, the ward was ventilated regularly to ensure sufficient sunlight, and hot compression was applied to the waist, knees, and abdomen. For abdominal distension, moxibustion was performed at the Pishu and bilateral Shenshu acupoints.


## 2.4. Outcome Measures

(1)
Nursing outcomes: the nursing outcomes included blood creatinine, fasting glucose, urea nitrogen, and proteinuria. Blood creatinine, urea nitrogen, and proteinuria levels were determined before and after the nursing using an immunoenzymatic assay with a fully automated biochemical analyzer. The fasting blood glucose level of the patients was determined using the Myriad BS-350 automatic biochemical analyzer with matching reagents of the analyzer. The lower the level of the above indexes, the better the nursing outcome.(2)
Inflammatory response indexes: the main indexes included interleukin (IL)-6, high-sensitivity C-reactive protein (hs-CRP), and tumor necrosis factor-alpha (TNF-α). 5 ml of fasting elbow venous blood was collected before and after the intervention, and the levels of IL-6, hs-CRP, and TNF-α were determined by ELISA. The specific operation was performed according to the instructions of the kit. The lower the level of the above-mentioned inflammatory response indexes, the better the nursing outcomes.(3)
Negative emotions: the self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to assess the psychological status of the patients. SAS: <50 points indicate no anxiety, 50–59 points indicate mild anxiety, 60–69 points indicate moderate anxiety, and >70 points indicate severe anxiety. <53 points indicate no depression, 53–62 points indicate mild depression, 63–72 points indicate moderate depression and >73 points indicate severe depression. The lower the score, the better the psychological status of the patient.


## 2.5. Statistical Analysis

SPSS 22.0 was used for data analyses. The measurement data were expressed as (x¯ ± s) and processed using the independent sample t-test. The count data were expressed as the number of cases (rate) and analyzed using the chi-square test. Differences were considered statistically significant at P<0.05.


## 3. Results

### 3.1. Nursing Outcomes

Primary nursing resulted in lower levels of blood creatinine, fasting glucose, urea nitrogen, and proteinuria versus routine nursing (P<0.05) (Table 2).Table 2
Comparison of nursing outcomes (x¯ ± s).
GroupsnBlood creatinine (mmol/L)Fasting glucose (mmol/L)Before nursingAfter nursingBefore nursingAfter nursingRoutine group40353.41 ± 12.78237.56 ± 11.1013.57 ± 1.769.32 ± 1.31Primary group40353.27 ± 12.59221.52 ± 10.1313.69 ± 1.727.11 ± 1.02t-value—0.0496.751-0.3088.419P value—0.961＜0.0010.759＜0.001GroupsnUrea nitrogen (mmol/L)Proteinuria (g/24 h)Before nursingAfter nursingBefore nursingAfter nursingRoutine group4018.53 ± 2.2712.56 ± 2.362.85 ± 1.142.82 ± 1.05Primary group4018.42 ± 2.368.63 ± 2.602.91 ± 1.031.11 ± 0.59t-value—0.2127.079-0.2478.98P value—0.833＜0.0010.806＜0.001


### 3.2. Inflammatory Responses Indices

Patients in the primary group had significantly lower levels of IL-6, hs-CRP, and TNF-α than those in the routine group (P<0.05) (Table 3).Table 3
Comparison of inflammatory responses indices (x¯ ± s).
GroupsnIL-6 (pg/ml)Hs-CRP (mg/L)TNF-α (pg/ml)Before nursingAfter nursingBefore nursingAfter nursingBefore nursingAfter nursingRoutine group402.34 ± 0.811.62 ± 0.5710.83 ± 2.678.35 ± 2.1064.83 ± 9.8256.28 ± 5.77Primary group402.27 ± 0.851.11 ± 0.3410.92 ± 2.596.11 ± 1.6864.80 ± 9.7945.32 ± 5.21t-value—0.3774.86−0.1535.2680.0148.916P value—0.707＜0.0010.879＜0.0010.989＜0.001


### 3.3. SAS and SDS Scores

The patients receiving primary nursing showed significantly lower scores of SAS and SDS than those given routine nursing (P<0.05) (Table 4).Table 4
Comparison of SAS and SDS scores (x¯ ± s).
GroupsnSAS scoresSDS scoresBefore nursingAfter nursingBefore nursingAfter nursingRoutine group4056.83 ± 3.4536.56 ± 3.5856.89 ± 3.7639.28 ± 3.31Primary group4056.77 ± 3.5922.13 ± 3.1556.92 ± 3.7220.56 ± 2.87t-value—0.07619.139−0.03627.025P value—0.94＜0.0010.971＜0.001


## 3.1. Nursing Outcomes

Primary nursing resulted in lower levels of blood creatinine, fasting glucose, urea nitrogen, and proteinuria versus routine nursing (P<0.05) (Table 2).Table 2
Comparison of nursing outcomes (x¯ ± s).
GroupsnBlood creatinine (mmol/L)Fasting glucose (mmol/L)Before nursingAfter nursingBefore nursingAfter nursingRoutine group40353.41 ± 12.78237.56 ± 11.1013.57 ± 1.769.32 ± 1.31Primary group40353.27 ± 12.59221.52 ± 10.1313.69 ± 1.727.11 ± 1.02t-value—0.0496.751-0.3088.419P value—0.961＜0.0010.759＜0.001GroupsnUrea nitrogen (mmol/L)Proteinuria (g/24 h)Before nursingAfter nursingBefore nursingAfter nursingRoutine group4018.53 ± 2.2712.56 ± 2.362.85 ± 1.142.82 ± 1.05Primary group4018.42 ± 2.368.63 ± 2.602.91 ± 1.031.11 ± 0.59t-value—0.2127.079-0.2478.98P value—0.833＜0.0010.806＜0.001


## 3.2. Inflammatory Responses Indices

Patients in the primary group had significantly lower levels of IL-6, hs-CRP, and TNF-α than those in the routine group (P<0.05) (Table 3).Table 3
Comparison of inflammatory responses indices (x¯ ± s).
GroupsnIL-6 (pg/ml)Hs-CRP (mg/L)TNF-α (pg/ml)Before nursingAfter nursingBefore nursingAfter nursingBefore nursingAfter nursingRoutine group402.34 ± 0.811.62 ± 0.5710.83 ± 2.678.35 ± 2.1064.83 ± 9.8256.28 ± 5.77Primary group402.27 ± 0.851.11 ± 0.3410.92 ± 2.596.11 ± 1.6864.80 ± 9.7945.32 ± 5.21t-value—0.3774.86−0.1535.2680.0148.916P value—0.707＜0.0010.879＜0.0010.989＜0.001


## 3.3. SAS and SDS Scores

The patients receiving primary nursing showed significantly lower scores of SAS and SDS than those given routine nursing (P<0.05) (Table 4).Table 4
Comparison of SAS and SDS scores (x¯ ± s).
GroupsnSAS scoresSDS scoresBefore nursingAfter nursingBefore nursingAfter nursingRoutine group4056.83 ± 3.4536.56 ± 3.5856.89 ± 3.7639.28 ± 3.31Primary group4056.77 ± 3.5922.13 ± 3.1556.92 ± 3.7220.56 ± 2.87t-value—0.07619.139−0.03627.025P value—0.94＜0.0010.971＜0.001


## 4. Discussion

Diabetic nephropathy is one of the major complications of diabetic patients, and diabetic nephropathy complicated by end-stage renal disease is the main cause of death in diabetic patients. Hemodialysis is an effective means for diabetic nephropathy, but prolonged hemodialysis may lead to inflammation, hypoproteinemia, muscle protein depletion, and other nutritional deficiencies in the organism, which reduces the immunity of patients, aggravates the inflammatory response, and compromises the prognosis [9]. A related study by Lee et al.[10] revealed that effective nursing measures for patients with diabetic nephropathy are essential for reducing clinical mortality and improving the quality of survival of patients [11]. Patient-oriented primary nursing is appreciated in clinical practice. Patients are given systematic and targeted nursing measures to reduce the incidence of complications and are instructed in terms of psychological management, medication, diet, and health education [12]. Clinical studies have shown that primary nursing facilitates the recovery of patients and lays a good foundation for the rehabilitation of patients. Diabetic nephropathy usually develops in the terminal stage of the disease due to the insidiousness of its early-stage symptoms, which complicates the treatment [13]. Currently, proteinuria, blood creatinine, and urea nitrogen are mostly determined in clinical practice by means of serological tests of renal function. Proteinuria levels reflect the severity of kidney damage and early nephropathy in patients. Blood creatinine is a product of human muscle metabolism in clinical practice and can be used to inspect renal function. Urea nitrogen is a nitrogenous compound in the plasma of the patient’s organism that is filtered from the glomerulus and excreted out of the body, which is generally used to determine the severity of the disease. Fasting glucose can be used to assess the glycemic index of the patient [14].The results of the present study showed that primary nursing resulted in lower levels of blood creatinine, fasting glucose, urea nitrogen, and proteinuria versus routine nursing, indicating that primary nursing is effective in improving renal function and controlling glycemic index in patients [15], which may be attributed to the scientific and reasonable targeted disease guidance and diet of the primary nursing. Ren et al. [16] found that inflammatory factors such as interleukin (IL)-6, hypersensitive c-reactive-protein (hs-CRP), and tumor necrosis factor-α (TNF-α) in patients with diabetic nephropathy accelerated the renal vascular sclerosis lesions in the body, which reduces the vascular elasticity and stimulates the proliferation of glomerular thylakoid cells in the body, thereby aggravating the disease. Thipsawat et al. [17] stated that the control of inflammatory response and proteinuria in patients with diabetic nephropathy contributed to the alleviation of impaired renal function in patients. Vlachou et al. [18] demonstrated that effective nursing interventions in patients with diabetic nephropathy treated with hemodialysis mitigated the inflammatory response and improved the patient’s prognosis. Moreover, primary nursing herein was associated with significantly lower levels of IL-6, hs-CRP, and TNF-α versus routine nursing, suggesting an effective alleviation of inflammatory response after the intervention of primary nursing. The reason may be that primary nursing closely monitors the patient’s conditions and the medication, which allows first response strategies in the case of any adverse conditions [19]. In addition, a sound physical and mental health status contributes to the enhancement of patients’ treatment outcomes [20]. Here, the patients receiving primary nursing showed significantly lower scores of SAS and SDS versus those given routine nursing, indicating a promising efficiency of primary nursing in eliminating the negative emotions of patients. The reason may be that primary nursing provides timely comfort and encouragement to help patients resolve their negative emotions [21]. It is worth noting that patients experience negative psychological changes after the illness. The task of psychological nursing is to improve the patient’s psychological state and help them adapt to the new status, which is beneficial to the treatment and recovery. However, important limitations should be outlined. The sample studied comprised a select and relatively small number of participants, which compromise the generalizability of the findings.


## 5. Conclusion

Primary nursing improves the renal function of diabetic nephropathy patients undergoing hemodialysis, reduces the inflammatory response, and eliminates the negative emotions of patients, which shows great potential for clinical application.



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*Source: 1011415-2022-08-09.xml*