关键词: 慢性肾脏病, 疾病管理, 社区卫生服务, 肾损伤

Abstract: Background　Compared to the mature management of chronic diseases such as hypertension，diabetes，coronary heart disease and cerebral hemorrhage，the management of chronic kidney disease（CKD） is still basically blank.Objective　The effects and significance of this work was analyzed by observing the changes of patients' indicators through the community-family-self-management of early CKD patients for three years.Methods　Using random system sampling method to screen early CKD patients in Fangzhuang Community Health Service Center and its subordinate stations from 10 December 2013 to 9 March 2014，and community-family-self management of these patients was implemented for three years.Physical examination indicators，incidence of urine abnormalities，drug adherence and follow-up compliance，CKD stages，acute eGFR decline events，number of hospitalizations，endpoint events，and short form 36 health survey（SF-36） scores before and after the three-year intervention were compared.Results　In this study，60 patients with CKD were selected，and one patient was lost.A total of 59 patients were included.At six months after the intervention，the levels of systolic pressure，diastolic pressure，HbA1c，TC，LDL-C，Cr，and UA were lower than those before the intervention；the eGFR levels of patients with stage 2 CKD and all patients were higher than those before the three-year intervention（P<0.05）.There were no significant differences in the levels of BUN，the eGFR levels of patients with stage 1 CKD and stage 2 CKD，and the eGFR levels of all patients before and after the three-year intervention（P>0.05）.The levels of systolic pressure，diastolic pressure，HbA1c，TC，LDL-C，TG，Cr，and UA were lower than those before the three-year intervention（P<0.05）.There were no significant differences in the levels of Cr，BUN，the eGFR levels of patients with stage 1 CKD and stage 2 CKD，and the eGFR levels of all patients after the intervention for half a year and three years（P>0.05）.At three years after the intervention，the levels of systolic pressure，diastolic pressure，HbA1c，TC，LDL-C，TG，and UA were lower than those at six months after the intervention（P<0.05）.The incidence of urine abnormalities was statistically significant before and after the intervention（χ2=53.149，P<0.01）.Before intervention，40（67.0%） patients had high drug adherence；21（35.6%） patients had high follow-up compliance.In the first year after intervention，51（86.9%） patients had high drug adherence；48（80.5%） patients had high follow-up compliance.In the third year after intervention，54（92.4%） patients had high drug adherence；50（85.2%） patients had high follow-up compliance.There were 19（32.2%）patients with stage 1 CKD and 40（67.8%） patients with stage 2 CKD before the intervention.There were 26（44.1%）patients with stage 1 CKD，32（54.2%）patients with stage 2 CKD，and 1（1.7%）patient with stage 3 CKD after the three-year intervention.In the six months and one year after the intervention，1（1.7%） patient had an acute eGFR decline and 1（1.7%） patient was hospitalized.No other end point events occurred.The PF，RP，BP，GH，PCS，VT，SF，RE，MH，and MCS scores of patients after the three-year intervention were higher than those before the intervention（P<0.05）.Conclusion　After the management of early CKD patients using community-family-self-management model，the risk factors such as blood pressure，blood sugar，and blood lipids can be effectively controlled，and metabolic indicators such as Cr，BUN and UA also show a declining trend.The standard management improves patients' drug adherence and follow-up compliance，and reduces the acute eGFR decline events.In terms of the incidence of acute eGFR decline events and urine abnormalities，this intervention can reduce kidney damage in the short term and delay the progression of kidney damage in the long term.The community-family-self-management model has a certain effect on the management of patients with early CKD.

Key words: 基金项目：北京市科委2013年重大课题项目（D131100004713002）&mdash, &mdash, &ldquo, 社区卫生服务机构-二级医院-三级医院&rdquo, CKD分级管理的适宜技术研究