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。

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.