慢性肾脏病患者健康管理的实践研究

Health management for patients with chronic kidney disease

目的探讨慢性肾脏病(chronic kidney disease,CKD)健康管理的方法和效果。方法建立由医生、护士、营养师组成的规范化CKD健康管理团队,采用慢性肾脏病信息化管理系统,对2015年10月—2017年4月肾内科门诊CKD3期和CKD4期的170例患者,通过收案、评估、干预指导、积极追踪4个环节,进行定期门诊随访、血压控制、用药指导、营养干预等无缝隙管理,并在干预前后对各项生化指标进行检测。结果干预后,170例患者的血尿素氮、血肌酐、血压低于干预前(P<0.05),肾小球滤过率、血浆白蛋白高于干预前(P<0.05),BMI达标率高于干预前(P<0.05)。结论构建的CKD健康管理体系,能延缓患者肾功能的恶化,改善CKD患者营养状况。

Objective To explore the methods and effects of health management for chronic kidney disease （CKD）. Methods A muhidisciplinary team was built up including physicians,nurses,and nutritionists. The informati- zation system for CKD management was adopted. A total of 170 patients with CKD 3 and CKD 4 were recruited in the study when they visited the outpatient departments from October 2015 to April 2017. A series of assess- ment,health education ,and follow-up consisting of regular follow-up at outpatient department,blood pressure control, medication education,and nutritional support were provided to the patients. The biochemical indicators were collect- ed before and after the interventions. Results After the invention,the levels of serum creatinine, blood urea nitrogen,and blood pressure were lower than those before the intervention（P〈0.05）. The glomerular filtration rate,plasma albumin,and normal BMI were higher after the intervention （P〈0.05）. Conclusion The CKD health management system can delay the deterioration of renal function and improve the nutrition condition of patients with CKD.