Objective: To improve the prevention and treatment of chronic kidney disease (CKD) incommunity.Method: 273 patients(112males and 161 females) with mean age 78.6±6.2, met the diagnosticcriteria for CKD by screening in community clinic high risk population .There were 96patients treated innephrology department(group A), while 177 patients treated in community(group B).To observe therapeuticsituations in the two groups.Result: After following up the two groups , the disease-improvement rate ingroup A was 70.8% and 25.4% in group B.The stable disease rate in group A was 54.2% and 21.9% ingroup B.The clinic exacerbation rate in group A was 20.3%and 7.3%in group B.So the two groups had significantdifference statistically.Conclusion: If general practitioners provide CKD patients in community withearly screening, intervention and timely referral , CKD can be greatly slowed down or controlled, thus to reducehuge consumption of medical resources.%目的：为探索如何更好的在社区防治慢性肾脏病（ CKD）。方法：筛选在我院社区门诊就诊的慢性肾脏病高危人群，符合慢性肾脏病诊断的病例有273例，其中男性112例，女性161例，平均年龄78．6±6．2岁。转诊到我院肾内科治疗共96例，留在社区指导的有177例，观察比较二组病情归转状态。结果：跟踪随访CKD患者两组比较发现：病情改善以医院组明显（70．8％）；社区组为25．4％；病情稳定以社区组为明显54．2％，医院组为21．9％；而病情恶化组以社区组20．3％，医院组为7．3％，两组之间的差异具有明显统计学差异。结论：社区人群的CKD患者如能通过全科医生对此类人群早期筛查，早期干预，及时的转诊，同时给予规范的健康管理，将能大大延缓和控制CKD的病情，相应遏制由此产生的巨额医疗资源的消耗。
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