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

摘要： 背景　相比发展成熟的高血压、糖尿病、冠心病、脑出血等慢性病管理技术，慢性肾脏病（CKD）患者的管理基本为空白。目的　通过对社区早期CKD患者进行为期3年的社区-家庭-自我管理，观察患者指标变化，分析此项工作的效果和意义。方法　于2013-12-10至2014-03-09，采用随机系统抽样方法筛选方庄社区卫生服务中心及下属站早期CKD患者，对患者实施社区-家庭-自我管理，共3年。对比干预前后患者体检指标、尿液异常发生率、用药依从性和随访依从性、CKD分期、估算肾小球滤过率（eGFR）急性下降事件、住院次数、终点事件、健康调查简表（SF-36）评分。结果　本研究选取CKD患者60例，失访1例，共纳入59例。干预后半年收缩压、舒张压、糖化血红蛋白（HbA1c）、总胆固醇（TC）、低密度脂蛋白胆固醇（LDL-C）、肌酐（Cr）、尿酸（UA）水平低于干预前，CKD 2期者eGFR水平、所有患者eGFR水平高于干预前（P<0.05）。干预前和干预后3年尿素氮（BUN）、CKD 1期者eGFR水平、CKD 2期者eGFR水平、所有患者eGFR水平比较，差异均无统计学意义（P>0.05）；干预后3年收缩压、舒张压、HbA1c、TC、LDL-C、三酰甘油（TG）、Cr、UA水平低于干预前（P<0.05）。干预后半年和干预后3年Cr、BUN、CKD 1期者eGFR水平、CKD 2期者eGFR水平、所有患者eGFR水平比较，差异均无统计学意义（P>0.05）；干预后3年收缩压、舒张压、HbA1c、TC、LDL-C、TG、UA水平低于干预后半年（P<0.05）。干预前后，尿液异常发生率比较，差异有统计学意义（χ2=53.149，P<0.01）。干预前，用药依从性高者40例（67.0%），随访依从性高者21例（35.6%）；干预后1年，用药依从性高者51例（86.9%），随访依从性高者48例（80.5%）；干预后3年，用药依从性高者54例（92.4%），随访依从性高者50例（85.2%）。干预前，CKD 1期者19例（32.2%），CKD 2期者40例（67.8%）；干预后3年，CKD 1期者26例（44.1%），CKD 2期者32例（54.2%），CKD 3期者1例（1.7%）。干预后半年及1年，各有1例（1.7%）患者发生eGFR急性下降事件；干预后半年及1年，各有1例（1.7%）患者住院。无其他终点事件发生。干预后3年患者生理功能（PF）、生理职能（RP）、躯体疼痛（BP）、总体健康状况（GH）、生理健康（PCS）、活力（VT）、社会功能（SF）、情感职能（RE）、精神健康（MH）和心理健康（MCS）评分均高于干预前（P<0.05）。结论　采用社区-家庭-自我管理模式对早期CKD患者管理后，危险因素血压、血糖、血脂可以得到有效控制，代谢指标Cr、BUN、UA也呈现下降状态；规范的管理使患者用药和随访依从性改善，减少eGFR急性下降事件。从eGFR和尿液异常发生率来看，该项干预近期内可减轻肾脏损害，远期可延缓肾脏损害的进展。社区-家庭-自我管理对早期CKD有一定的效果。

关键词: 慢性肾脏病, 疾病管理, 社区卫生服务, 肾损伤