两种连续肾脏替代纠正乳酸酸中毒的临床观察

Clinical investigation of continuous venous-venous hemofiltration and continuous venous-venous hemodialysis on lactic acidosis

目的 比较持续静脉-静脉血液滤过（CVVH）和持续静脉-静脉血液透析（CVVHD）两种肾脏替代治疗方法对乳酸酸中毒纠正的效果.方法 采用前瞻性随机对照的研究方法,选择2009年4月到2013年4月期间在香港大学深圳医院及汕头大学医学院第一附属医院重症监护科（ICU）住院的危重症患者137例.入选标准：符合乳酸酸中毒诊断的患者.排除标准：晚期恶性肿瘤患者和临终状态者.按随机对照的原则,将137例入选患者分为两组,其中接受持续静脉-静脉血液滤过治疗组70例,接受持续静脉-静脉血液透析治疗组67例.两组患者均在CRRT治疗前及治疗后4、8、12、24、48 h监测血乳酸及动脉血气,统计两组患者的住院病死率及ICU留治时间.统计使用SPSS 15.0统计分析软件.结果 相同剂量的CVVH和CVVHD在清除血乳酸的效率[血乳酸水平治疗后4 h （11.65±3.39） mmol/L vs.（11.12±2.65） mmol/L;8 h（8.78 ±2.35）mmol/L vs.（8.59 ±2.09） mmol/L; 12 h（6.91±1.67） mmol/L vs.（6.74±1.76） mmol/L; 24 h（1.66±0.39） mmol/L vs.（1.51 ±0.30） mmoL/L; 48 h（0.95±0.24） mmol/L vs.（0.66 ±0.20）mmol/L,P＞0.05]及对pH值的影响[pH值治疗后4 h（6.93±0.14） vs.（7.05±0.09）;8 h（7.04±0.10） vs.（7.12±0.05）;12h （7.13±0.07） vs.（7.20±0.04）; 24 h（7.30±0.03）vs.（7.38 ±0.04）;48 h（7.41 ±0.03） vs.（7.46 ±0.02）,P＞ 0.05]方面差异无统计学意义,CVVH和CVVHD两组患者的住院病死率（11.4％ vs.10.4％,P=0.854）及存活患者的ICU留治时间[（9.5±2.4） dvs.（8.8±2.9）d,P=0.329],差异亦无统计学意义.结论 CVVH和CVVHD两种方式的持续血液净化均能有效清除患者的血乳酸,纠正患者的酸碱平衡失调;两种方式对患者留治ICU的时间及住院病死率的影响无明显差别.

Objective To investigate the effect of continuous venous-venous hemofiltration （CVVH） and continuous venous-venous hemodialysis （CVVHD） on patients with lactic acidosis.Methods A total of 137 cases with lactic acidosis were included in this prospective randomized control study.lhe patients were collected from the University of Hong Kong-shenzhen Hospitall and the First Affiliated Hospital of Shantou University Medical College from April 2009 to April 2013.Inclusion criteria were patients with lactic acidosis.Exclusion criteria were patients with end-stage malignancy or terminal stage of illnesses.The patients were randomly divided into two groups：CVVH group and CVVHD group,and patients of both group were intervened with conventional treatments as well.For each group,the lactic acid and blood gas analysis were tested before CRRT,and at 4 hours,8 hours,12 hours,24 hours,and 48 hours of CRRT.The patients＇ mortality and length of ICU stay time were analysed and recorded.Statistical analysis was performed using SPSS 15.0software.Results When the length of time for treatment was the same,the efficacy between CVVH group and CVVHD group showed no difference in blood lactic acid level [4 h：（11.65 ± 3.39） mmol/L vs.（11.12±2.65） mmol/L; 8 h：（8.78±2.35） mmol/L vs.（8.59±2.09） mmol/L; 12 h：（6.91 ±1.67）mmol/Lvs.（6.74±1.76） mmol/L;24h：（1.66±0.39） mmol/Lvs.（1.51±0.30） mmol/L; 48 h：（0.95 ±0.24） mmol/L vs.（0.66 ±0.20） mmol/L,P 〉 0.05） and pH value [4 h：（6.93 ±0.14） vs.（7.05±0.09）;8h：（7.04±0.10）vs.（7.12±0.05）; 12h：（7.13±0.07）vs.（7.20±0.04）;24h：（7.30±0.03） vs.（7.38±0.04）; 48h：（7.41 ±0.03） vs.（7.46±0.02）,P〉 0.05].There are also no difference in the hospital mortality （11.4% vs.10.4%,P=0.854） and length ofICU stay time [（9.5 ±2.4） d vs.（8.8 ± 2.9） d,P =0.329].Conclusions Both CVVH and CVVHD can effectively correct hyperlactemia,enhance acid-base balance,contributing no differences in length of ICU stay time and patients＇ hospital mortality.