Dean John
Calderdale and Huddersfield NHS Foundation Trust, Yorkshire, UK.
J Ren Care. 2012 Feb;38 Suppl 1:23-9. doi: 10.1111/j.1755-6686.2012.00272.x.
Diabetes and chronic kidney disease (CKD) are two of the commonest long-term conditions. One-fifth of patients with diabetes will have CKD, and diabetes is the commonest cause of advanced kidney disease. For most patients these comorbidities will be managed in primary care with the focus on cardiovascular prevention. Many patients with more advanced disease and complications require joint care from multidisciplinary specialist teams in diabetes and renal disease to ensure that care is consistent and coordinated. Models of joint speciality care, include joint registry management, parallel clinics, shared consulting and case discussion, but require more evaluation than has currently been performed. These underpin more informal interactions between the specialist teams. A local model of care for diabetes and renal disease that incorporates the roles of primary care, members of multidisciplinary teams and speciality care should be agreed, resourced appropriately and its effectiveness monitored.
糖尿病和慢性肾脏病（CKD）是两种最常见的长期病症。五分之一的糖尿病患者会患有CKD，且糖尿病是晚期肾病最常见的病因。对于大多数患者而言，这些合并症将在初级医疗保健中进行管理，重点是心血管疾病预防。许多病情更严重以及有并发症的患者需要糖尿病和肾病多学科专家团队的联合护理，以确保护理的连贯性和协调性。联合专科护理模式包括联合登记管理、并行诊所、联合咨询和病例讨论，但需要比目前更多的评估。这些模式为专家团队之间更非正式的互动奠定了基础。应该商定一种结合初级医疗保健、多学科团队成员和专科护理作用的糖尿病和肾病地方护理模式，为其提供适当资源并监测其有效性。
