Background and objectives: " Integrated Chronic Kidney Disease（CKD）care program " has been implemented in Taiwan since 2003 but its effectiveness on the revisit generally diminishes with time. How to maintain the effectiveness has become a pivotal issue in general care. This study was aimed to examine the effectiveness of the " integrated CKD care program " and the factors impacting the effectiveness of the program in chronic kidney disease patients. Methods: A total of 1120 patients out from one medical center in middle Taiwan were included in this study . The characteristics of lab data, and the results of revisit of these patients were collected and analyzed . Results: The results indicate the integrated CKD care program significantly reduced the rate of dialysis at one year follow up. A regular revisit and adhering to the treatment plans appear to be the major factors for preventing the rest of dialysis. Conclusion：An effective lifestyle education is probably the key in maintaining and extending the beneficial effects of the integrated CKD care program .