Abstract: Diabetic kidney disease（DKD）, an important diabetes-induced microvascular complication, has become the leading cause of chronic kidney disease in China. DKD is associated with a significantly increased risk for cardiovascular disease, leading to an increased risk of mortality and bringing heavy financial burdens to the patient' family as well as the society. This paper reviews the status of community-based management of DKD in China, describes the patterns of management, and explores the ways for comprehensive management of DKD in the regional medical consortium. Moreover, it summarizes that community-based management of DKD in China is still in the initial phase；multiple interventions can significantly improve the risk factors of DKD；general practitioner team-based management and municipal-prefectural-community health institutions based management are two major management patterns for DKD；the implementation of community-based hierarchical and individualized management of DKD faces many challenges；optimized community-based comprehensive management for different stages of DKD is expected to be achieved by hierarchical diagnosis and treatment in combination with the Internet technologies and the support of government policies.

Key words: Diabetic kidney disease, Community health services, Integrated management, Model

摘要： 糖尿病肾脏疾病（diabetic kidney disease，DKD）是糖尿病重要的微血管并发症之一，也是目前我国慢性肾病的首要原因，合并DKD后，糖尿病患者心脑血管疾病风险明显升高，死亡率增加的同时给患者、家庭及社会带来沉重的经济负担。本文通过对目前DKD社区管理现况进行综述，阐述目前社区DKD的管理现状及管理模式，探索在医联体模式下如何实现对DKD的综合管理。目前我国社区DKD管理尚处于初步阶段，采取多种措施进行干预管理可明显改善DKD患者多项危险因素；管理模式主要为全科医生团队管理模式和“市级-区级-社区”管理模式，社区DKD分层个性化管理仍面临着诸多挑战，未来在分级诊疗模式下通过“互联网+”及政策支持有望实现社区对DKD患者全程最优化综合管理。

关键词: 糖尿病肾病, 社区卫生服务, 综合管理, 模式