Bhumirajanagarindra Kidney Institute, Bangkok, Thailand.
Khlong Lan Hospital, Kamphaeng Phet, Thailand.
Nephrology (Carlton). 2021 Apr;26(4):333-340. doi: 10.1111/nep.13849. Epub 2021 Feb 2.
We conducted a prospective cohort study to evaluate the effectiveness of an integrated care model on delaying chronic kidney disease (CKD) progression in routine clinical practice in rural primary care setting.
After enrolment, patients with stages 3 to 4 CKD patients from five district hospitals in a northern province of Thailand (400 km from Bangkok) received integrated care comprising hospital multidisciplinary care and home visits by community care teams. Clinical characteristics and biochemical data were collected at baseline and every 3-month interval thereafter for 36 months. The primary outcome was the rate of estimated glomerular filtration rate (eGFR) decline.
Nine hundred and fourteen stage -3 and - 4 CKD patients were enrolled. The mean age of our cohort was 62 years. Diabetic kidney disease (DKD) was the main cause of CKD (53%) whereas hypertension was the most common co-morbidity (92%). The mean rate of eGFR decline was -0.92 mL/min/1.73 m /year. The rate of eGFR decline among patients with DKD was about three times faster than patients without DKD. Patients with higher blood pressure, metabolic acidosis, proteinuria or anaemia had a faster rate of eGFR decline.
This integrated care model at the community level was effective in delaying CKD progression in routine clinical practice situation.
我们开展了一项前瞻性队列研究，旨在评估在泰国北部一个农村初级保健环境的常规临床实践中，综合护理模式对延缓慢性肾脏病（CKD）进展的效果。
在入组后，来自泰国北部一个省的五家地区医院的 3 至 4 期 CKD 患者（距离曼谷 400 公里）接受了综合护理，包括医院多学科护理和社区护理团队的家访。在基线和此后每 3 个月收集临床特征和生化数据，共 36 个月。主要结局是估算肾小球滤过率（eGFR）下降率。
共纳入了 914 名 3 期和 4 期 CKD 患者。我们队列的平均年龄为 62 岁。糖尿病肾病（DKD）是 CKD 的主要病因（53%），而高血压是最常见的合并症（92%）。eGFR 下降的平均速率为-0.92mL/min/1.73m/year。DKD 患者的 eGFR 下降速度约为非 DKD 患者的三倍。血压较高、代谢性酸中毒、蛋白尿或贫血的患者 eGFR 下降速度较快。
在社区层面开展的这种综合护理模式在常规临床实践中能有效延缓 CKD 进展。
