Abstract: Background　At present，chronic kidney disease （CKD） has become one of the diseases that seriously threaten human health.Early detection，diagnosis and treatment of CKD，prevention and treatment of various reversible factors and delay of progression of kidney disease，are the problems that medical workers must face.Objective　To explore the effect of family doctor-led team-based early kidney disease management in elderly CKD patients.Methods　From November to December 2017，by the lottery number drawn subjectively，400 eligible patients with confirmed early CKD were selected from Huangdu Community Health Center，and were equally divided into control group（routine examination） and intervention group（family doctor-led team-based early kidney disease management，including health education，health management，individualized drug treatment and regular examination） by tossing a coin.The intervention for both groups lasted for 18 months.Comparisons were made between pre- and post-intervention anthropometry indices 〔body mass index （BMI），systolic blood pressure （SBP），diastolic blood pressure （DBP）〕 and blood biochemical indicators 〔（fasting blood glucose （FPG），glycosylated hemoglobin （HbA1c），serum creatinine （Scr），blood urea nitrogen （BUN），serum uric acid （SUA），estimated glomerular filtration rate （GFR），urine albumin（ALB），urine creatinine （Ucr），total cholesterol （TC），triglyceride （TG），high-density lipoprotein （HDL），and low-density lipoprotein （LDL）〕.End of June 2019，the end-point events （including all-cause death，all-cause hospitalization and dialysis） of patients were recorded.Results　Except that，1 case in the intervention group and 2 cases in the control group were lost to follow up，other cases were included in the final analysis.After intervention，the intervention group showed lower mean levels of BMI，SBP，DBP，FPG，HbA1c，Scr，BUN，SUA，ALB，Ucr，TC，TG，and LDL，and higher mean levels of GFR and HDL than the control group （P<0.05）.Mean levels of BMI，SBP，DBP，FPG，HbA1c，Scr，BUN，SUA，ALB，Ucr，TC，TG，and LDL decreased significantly and mean levels of GFR and HDL increased significantly in the intervention group compared with baseline levels（P<0.05）.By the end of June 2019，37 patients（9.3%） had end-point events，including 4 all-cause deaths （1 due to respiratory failure and 3 due to heart failure）.20 patients were hospitalized for all causes，mainly due to the deterioration of basic diseases，poor blood pressure and blood glucose control，and the onset of cardiovascular diseases.Dialysis was performed in 13 patients.The intervention group had higher all-cause hospitalization rate，but lower all-cause mortality rate and dialysis rate than the control group （P<0.05）.Conclusion　Family doctor-led team-based early kidney disease management has a good effect in elderly CKD patients，which is manifested as improving the blood biochemical indices，reducing the all-cause mortality and dialysis rate，and enhancing the quality of life.

Key words: Chronic disease, Nephrosis, General practitioners, Community health centers, Management model

摘要： 背景　目前慢性肾脏疾病（CKD）已成为严重威胁人类健康的疾病之一，早期发现、诊断和治疗 CKD，防治各种可逆因素和延缓肾脏疾病的进展，是医务工作者必须面对的问题。目的　探索以家庭医生为核心的早期肾脏疾病管理模式对老年CKD的管理效果。方法　2017年11—12月，采用随机抽签法从黄渡社区卫生服务中心抽取已确诊的符合研究标准的老年CKD患者400例，采用抛硬币法将患者分为对照组和干预组，每组200例。干预组患者采用以家庭医生为核心的早期肾脏疾病管理模式进行管理，主要包括开展健康宣教、健康管理、个体化的药物治疗及定期检查；对照组患者进行常规检查；干预18个月。比较两组患者干预前后人体测量学指标〔体质指数（BMI）、收缩压（SBP）、舒张压（DBP）〕和血生化指标〔空腹血糖（FPG）、糖化血红蛋白（HbA1c）、血肌酐（Scr）、血尿素氮（BUN）、血尿酸（SUA）、肾小球滤过率（GFR）、尿微量白蛋白（ALB）、尿肌酐（Ucr）、总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白（HDL）、低密度脂蛋白（LDL）〕。截至2019年6月底，记录终点事件（包括全因死亡、全因住院及进行透析）。结果　随访结束时，干预组失访1例，对照组失访2例。干预组干预后BMI、SBP、DBP、FPG、HbA1c、Scr、BUN、SUA、ALB、Ucr、TC、TG、LDL低于对照组，GFR、HDL高于对照组（P<0.05）。干预后干预组BMI、SBP、DBP、FPG、HbA1c、Scr、BUN、SUA、ALB、Ucr、TC、TG、LDL低于组内干预前，GFR、HDL高于组内干预前（P<0.05）。截至2019年6月底，共37例（9.3%）患者发生终点事件，包括全因死亡4例，其中死亡原因包括呼吸衰竭（1/4）和心力衰竭（3/4）；全因住院20例，住院的主要病因为基础疾病恶化、血压血糖控制不良及心血管疾病发作；进行透析13例。干预组患者全因住院率高于对照组，全因死亡率、透析率低于对照组（P<0.05）。结论　以家庭医生为核心的早期肾脏疾病管理模式对老年CKD患者管理效果较佳，能有效改善患者血生化指标，降低患者全因死亡率和透析率，提高患者生活质量。

关键词: 慢性病, 肾病, 全科医生, 社区卫生中心, 管理模式