社区慢性肾脏病的筛查与管理现状

doi:10.19723/j.issn.1671-167X.2022.05.036

北京大学学报（医学版） ›› 2022, Vol. 54 ›› Issue (5): 1056-封三. doi: 10.19723/j.issn.1671-167X.2022.05.036

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社区慢性肾脏病的筛查与管理现状

徐菱忆^1,²,惠淼^1,²,朱树宏^2,³,杨照^1,²,李梦蕊^1,²,杨宏宇^1,²,郑茜子^1,²,吕继成^1,^2,*(),杨莉^1,^2,*()

1. 北京大学第一医院肾内科，北京大学肾脏疾病研究所，卫生部肾脏疾病重点实验室，慢性肾脏病防治教育部重点实验室(北京大学)，中国医学科学院免疫介导肾病诊治创新单元，北京 100034
2. 社区智慧健康管理和人工智能应用联合实验室，北京 100034
3. 北京市西城区智慧健康研究中心，北京 100053

收稿日期:2022-06-22 出版日期:2022-10-18 发布日期:2022-10-14
通讯作者: 吕继成,杨莉 E-mail:jichenglv75@gmail.com;li.yang@bjmu.edu.cn
作者简介:杨莉，北京大学医学部教授、博士生导师，北京大学第一医院副院长、肾内科主任。现任中华医学会常务理事，亚太地区肾脏病学会急性肾损伤专业委员副主席，国际急性肾损伤急性透析质量倡议(Acute Dialysis Quality Initiative，ADQI)专家共识组专家，世界中医药联合会临床用药安全研究专业委员会副会长，美国肾脏生理学杂志编委，教育部长江学者特聘教授，国家卫生健康突出贡献中青年专家，国家杰出青年基金获得者，中国青年科技奖特别奖、中国青年女科学家奖、中华肾脏病学会青年研究者获得者，主持国家自然科学基金杰出青年科学基金、国家自然科学基金重点项目、国家自然科学基金重大研究计划重点支持项目、北京市高校卓越青年科学家计划等省部级科研基金项目，共发表SCI论文80余篇，代表性论文发表在Lancet、Nat Med、J Clin Invest、Adv Sci、J Am Soc Nephrol等期刊。
杨莉教授课题组长期致力于急性肾损伤发病机制和临床防治研究，牵头中国急性肾损伤流行病学调查，报告全国疾病负担，发现临床普遍存在严重漏误诊和治疗不当，报告地域特征性病因谱和风险防控环节，提出卫生经济学优化管理；提出中国急性肾损伤诊断改进方案，创建急性肾损伤自动化预警系统，有效降低漏误诊率；建立药物肾损伤预警与标准化多学科诊疗路径，降低药物毒性肾损伤发生率；研发尿沉渣诊断树及新型生物学标志物，建立早诊和鉴别诊断平台，推动急性肾损伤临床诊断能力提升；揭示急性肾损伤早期天然防御机制以及肾小管细胞修复不良机制，发现新靶点，为探索肾脏保护拓展新的研究方向
基金资助:
北京高校卓越青年科学家计划(BJJWZYJH01201910001006);中国医学科学院中央级公益性科研院所基本科研业务费专项(2020-JKCS-009);北大百度基金(2020BD026);北大百度基金(2020BD044);北京市科技新星计划(2021051);中国医学科学院医学与健康科技创新工程项目(2019-I2M-5-046);首都卫生发展科研专项(首发2022-1-4071)

Chronic kidney disease in community: Current state for screening and management

Ling-yi XU^1,²,Miao HUI^1,²,Shu-hong ZHU^2,³,Zhao YANG^1,²,Meng-rui LI^1,²,Hong-yu YANG^1,²,Xi-zi ZHENG^1,²,Ji-cheng LV^1,^2,*(),Li YANG^1,^2,*()

1. Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences; Beijing 100034, China
2. Joint Laboratory of Community Intelligent Health Management, Beijing 10034, China
3. Health Intelligence Research Center of Beijing Xicheng District, Beijing 100053, China

Received:2022-06-22 Online:2022-10-18 Published:2022-10-14
Contact: Ji-cheng LV,Li YANG E-mail:jichenglv75@gmail.com;li.yang@bjmu.edu.cn
Supported by:
the Beijing Outstanding Young Scientist Program(BJJWZYJH01201910001006);the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences(2020-JKCS-009);the PKU-Baidu Fund(2020BD026);the PKU-Baidu Fund(2020BD044);the Beijing Nova Program(2021051);the CAMS Innovation Fund for Medical Sciences(2019-I2M-5-046);the Capital's Funds for Health Improvement and Research(首发2022-1-4071)

摘要/Abstract

摘要：

目的: 了解社区成年慢性肾脏病(chronic kidney disease, CKD)高危人群的筛查及CKD患者的管理现状，探讨社区卫生机构CKD管理的改善措施。方法: 基于西城区卫生健康委员会下辖79家社区卫生服务站的全部医疗信息数据，建立西城区社区CKD一体化大数据平台，基于该数据平台纳入2015年7月21日至2021年11月20日期间就诊的社区患者，分析肾脏损伤相关指标的检测情况、肾脏病危险因素控制达标率、用药情况，并对社区卫生服务站的肾脏病检验能力进行评估。结果: 在374 498例社区患者中，70.6%为CKD高危人群，其CKD危险因素最常见的为高血压(62.3%)、冠心病(43.3%)和糖尿病(30.4%)，仅17.2%的CKD高危人群进行过肾脏病筛查，其中CKD检出率为24.2%(10 992/45 377例)。进行过肾脏病筛查的所有社区患者中(49 908例，13.3%)，CKD检出率为22.7%(11 338/49 908例)，42.6%存在估算肾小球滤过率(estimated glomerular filtration rate，eGFR) < 60 mL/(min·1.73 m²)，46.1%存在尿蛋白异常。社区人群中总体CKD检出率为5.2%(19 299/374 498例)，在社区医疗中CKD的总体漏诊率为38.1%。79个社区中，13个(16.5%)社区卫生中心配备尿蛋白定量(尿白蛋白/肌酐比值)检测，66个(83.5%)社区卫生中心能够直接报告eGFR检验结果。CKD患者中，60.3%血糖控制达标，99.7%血压控制达标。5 227例CKD合并蛋白尿的患者中，使用肾素-血管紧张素-醛固酮系统抑制剂治疗的比例为59.3%。结论: CKD高危人群在社区人群中所占比例大，在社区开展有效的CKD早期筛查和防治对改善其预后，减少疾病负担具有重要意义。健全和完善CKD筛查和监测系统、加强社区医师肾脏疾病相关知识培训和CKD规范化管理对提升社区CKD防治能力尤为重要。

关键词: 慢性肾脏病, 社区卫生服务, 疾病管理, 健康教育

Abstract:

Objective: To understand the current state and problem of screening and management of chronic kidney disease (CKD) in the community, and to explore the improving strategies. Methods: We established a community-CKD integrated data science platform based on medical information from 79 community health centers, in Xicheng District, Beijing. Patients who referred to 79 community health centers from 21 June 2015 to 20 November 2021 were retrospectively included in this study using the CKD data platform. The monitoring of the indicator of kidney injury, risk factor control, medicine use and device configuration in community were assessed in the study. Results: In the study, 70.6% of the population were identified with high risk of CKD in the total 374 498 individuals who referred to the community health centers. Hypertension (62.3%), coronary heart disease (43.3%) and diabetes (30.4%) were the most common risk factors in high-risk CKD population. Only 17.2% of the patients with high risk of CKD were screened for kidney injury including at least one serum creatine (Scr) or albuminuria test, among which 10 992 (24.2%) individuals were defined as CKD. 22.7% (11 338/49 908) of the total patients with kidney screening in community were defined as CKD, of whom, 42.6% and 46.1% were identified by estimated glomerular filtration rate (eGFR) < 60 mL/(min·1.73 m²) and abnormalities of urinary proteins, respectively. The overall CKD detection rate in the community was 5.2% (19 299/374 498), and the miss-diagnosis rate of CKD was 38.1%. Of the 79 community health centers, 13 (16.5%) were equipped with ACR testing device, and eGFR was reported directly in 66 (83.5%) centers. Altogether 60.3% and 99.7% of the community CKD patients achieved glucose control and blood pressure control, respectively, and 59.3% of the CKD patients who had proteinuria was treated with renin-angiotensin-aldosterone system (RAAS) inhibitors. Conclusion: High-risk CKD population account for a substantial proportion of patients who refer to the community. Early screening, prevention and management of CKD in the community are of great importance to improve the prognosis and decrease the burden of CKD. It's essential to establish a screening and monitoring system, strengthen standardized management and clinician training for improving the ability of CKD management in the community.

Key words: Chronic kidney disease, Community health services, Disease management, Health education

中图分类号:

R692

徐菱忆,惠淼,朱树宏,杨照,李梦蕊,杨宏宇,郑茜子,吕继成,杨莉. 社区慢性肾脏病的筛查与管理现状[J]. 北京大学学报（医学版）, 2022, 54(5): 1056-封三.

Ling-yi XU,Miao HUI,Shu-hong ZHU,Zhao YANG,Meng-rui LI,Hong-yu YANG,Xi-zi ZHENG,Ji-cheng LV,Li YANG. Chronic kidney disease in community: Current state for screening and management[J]. Journal of Peking University (Health Sciences), 2022, 54(5): 1056-封三.

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参考文献 18

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Items	Total population(n=374 498)	High-risk patients(n=264 514)	CKD patients(n=19 299)
Male	159 320 (42.5)	120 242 (45.5)	8 925 (46.2)
Age/years	58±16	65±12	67±12
BMI/(kg/m²)	24 (22, 26)	24 (23, 27)	25 (23, 27)
Insurance	304 951 (81.4)	229 141 (86.6)	18 228 (94.5)
Diabetes	80 455 (21.5)	80 455 (30.4)	9 788 (50.7)
Hypertension	164 851 (44.0)	164 851 (62.3)	15 719 (81.4)
MI	64 (0)	64 (0)	12 (0.1)
CHD	114 662 (30.6)	114 662 (43.3)	13 101 (67.9)
HF	1 966 (0.5)	1 966 (0.7)	344 (1.8)
COPD	3 333 (0.9)	3 213 (1.2)	514 (2.7)
Cancer	4 606 (1.2)	4 606 (1.7)	470 (2.4)
Follow-up/years	1.9±1.6	2.3±1.5	3.4±1.4

Items	Total CKD patients (n=19 299)		CKD patients diagnosed by ICD-10 (n=11 945)
Items	Detection rate	Control rate	Detection rate	Control rate
Blood glucose	5 372 (27.8)	3 240 (60.3)	2 012 (16.8)	1 253 (62.3)
Blood pressure	19 191 (99.4)	19 128 (99.7)	11 903 (99.6)	11 900 (100.0)
SBP	19 191 (99.4)	18 720 (97.5)	11 903 (99.6)	11 787 (99.0)
DBP	19 191 (99.4)	19 025 (99.1)	11 903 (99.6)	11 864 (99.7)
Hyperkalemia	7 719 (40.0)	154 (2.0)	2 850 (23.9)	81 (2.8)

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社区慢性肾脏病的筛查与管理现状

Chronic kidney disease in community: Current state for screening and management

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