慢性肾脏病(CKD)因具有患病率高、病死率高及知晓率低等特点,已成为威胁全球公共卫生安全的常见慢性非传染性疾病之一。CKD属生活方式疾病,通过对患者实施早期且持续的健康管理,可达到延缓CKD进展、改善患者生活质量、减少不良预后事件发生以及节省医疗成本等目的。本文通过借鉴国内外CKD患者管理经验,提出了以成立多学科协作的管理团队、建设信息化的互联网管理平台、实施分层分类的个案化管理等理念为架构的管理体系,同时强调了要重视对CKD高危人群——围透析期患者的管理,旨在为CKD患者提供更全面、更专业的医疗照护服务,帮助其提高自身管理能力。

Chronic kidney disease (CKD), due to its high prevalence, high fatality rate and low awareness rate, has become one of the common chronic non-communicable diseases that threaten global public health. CKD is a lifestyle disease. Early and continuous health management can help delay the progress of CKD, improve patients’ quality of life, reduce the occurrence of adverse prognostic events and save medical costs. By studying the management experience of CKD patients at home and abroad, this paper presents a system based on the concepts of establishing a multidisciplinary collaborative management team and an information-based Internet management platform, and implementing hierarchical and classified individualized management. In addition, the paper emphasized that attention should be paid to the management of "peri-dialysis" patients. The aim is to provide more comprehensive and professional medical care services for CKD patients and improve their self-management ability.