Abstract: Background　Although the overall prevalence of chronic kidney disease (CKD) in China has decreased, patients with hypertension and type 2 diabetes mellitus (hereinafter referred to as "the two diseases") have a relatively high risk of developing CKD, and the status of their standardized management in primary medical institutions remains unclear. Objective　To conduct a cross-sectional survey of patients with "the two diseases" in community health service centers regarding the prevalence and management status of CKD, so as to provide data support for optimizing the management of chronic kidney disease at the primary level. Methods　From January to December 2024, a two-stage random sampling method was adopted. Taking 12 community health service centers in Wuhou District, Chengdu as the sampling frame, 6 institutions were randomly selected, and then 600 eligible patients with "the two diseases" were randomly extracted from these selected institutions (including 205 cases of isolated hypertension, 213 cases of isolated type 2 diabetes mellitus, and 182 cases of comorbidity of the two diseases). The prevalence and management status of CKD in these patients were calculated, covering outpatient management, metabolic intervention, pharmacotherapy, and comprehensive intervention. Data were entered using EpiData 3.1 software, and statistical analysis was performed with SPSS 21.0 software. Results　Among the included population with "the two diseases", 173 cases (28.83%) were diagnosed with CKD. Of these CKD patients, 55 cases (26.83%) were from the isolated hypertension group, 52 cases (24.41%) were from the isolated type 2 diabetes mellitus group, and 66 cases (36.26%) were from the comorbidity group of the two diseases.Among all the CKD patients,39 cases (22.54%) were at CKD stage 3, 5 cases (2.89%) at CKD stage 4, and 1 case (0.58%) at CKD stage 5. However, only 9 cases (5.2%) were registered for the special outpatient service for chronic kidney disease, 70 cases (59.32%) achieved the target of blood glucose control, 112 cases (92.56%) reached the standard of blood pressure control, 64 cases (36.99%) took SGLT-2i/GLP-1RA drugs, and 90 cases (52.02%) administered ACEI/ARB drugs. Conclusion　At present, the prevalence of CKD in patients with the two diseases (diabetes/hypertension) in community health service centers of Wuhou District of Chengdu City is relatively high, and the standardized management of CKD patients remains inadequate. These findings indicate that primary medical institutions should improve the capacity for early screening and intervention of CKD, strengthen the standardized management of CKD patients, and enhance the control of patients' metabolic indicators, which is of great significance for effectively preventing and delaying disease progression.

Key words: Hypertension, Diabetes mellitus, type 2, Chronic kidney disease, Community health centers, Prevalence, Chronic disease management

摘要： 背景　我国慢性肾脏病（CKD）患病率虽总体呈下降趋势，但高血压和2型糖尿病（简称“两病”）患者的CKD患病风险较高，其在基层医疗卫生机构的规范化管理情况尚不明确。目的　了解社区卫生服务中心“两病”患者的CKD患病率及管理现状，为基层CKD管理优化提供数据支持。方法　于2024年1—12月，采用两阶段随机抽样法，从成都市武侯区12家社区卫生服务中心随机抽取6家，再从该6家社区卫生服务中心随机抽取符合条件的“两病”患者600例（单纯高血压205例、单纯2型糖尿病213例、“两病”共患182例）。统计“两病”患者的CKD患病率及管理现状，管理现状包括门诊管理、代谢控制、药物治疗及综合干预情况。采用EpiData 3.1软件录入数据，采用SPSS 21.0软件进行统计学分析。结果　“两病”患者的CKD检出率为28.8%（173/600）。其中，单纯高血压患者的CKD检出率为26.8%（55/205），单纯2型糖尿病患者的CKD检出率为24.4%（52/213），“两病”共患者的CKD检出率为36.3%（66/182）。合并CKD的“两病”患者中，CKD3期39例（22.5%），CKD4期5例（2.9%），CKD5期1例（0.6%），而慢性肾病特殊门诊办理率仅为5.2%（9/173），血糖达标率为59.3%（70/118），血压达标率为92.6%（112/121），SGLT-2i/GLP-1RA使用率为37.0%（64/173），ACEI/ARB使用率为52.0%（90/173）。结论　成都市武侯区社区卫生服务中心“两病”患者的CKD发生率较高，且CKD患者规范化管理不足。提示基层医疗卫生机构应提高CKD的早期筛查和干预能力，加强对CKD患者的规范化管理，改善患者代谢指标控制情况，这对有效预防和延缓疾病进展有重要意义。

关键词: 高血压；糖尿病, 2 型；慢性肾脏病；社区卫生服务中心；患病率；慢性病管理