慢性肾衰竭并发乳酸性酸中毒应用不同置换量CVVH的临床效果

Comparing the benefits of CVVH with various replacement solution volume in chronic renal failure patients with lactic acidosis

目的 比较不同置换量的连续性静－静脉血液滤过（CVVH）治疗慢性肾衰竭（CRF）合并乳酸性酸中毒的临床效果。方法 采用前瞻性随机对照方法，选择2016-07～2017-06在解放军第211医院肾内科救治的CRF合并乳酸性酸中毒24例患者，按照随机数字表法将患者随机等分到低置换量（SV-CVVH）组和高置换量（HV-CVVH）组。两组患者在常规综合治疗基础上，分别给予低置换量［35 mL/（kg·h）］、高置换量［65 mL/（kg·h）］CVVH持续治疗48 h。监测并比较两组患者治疗前及治疗24、48 h后血pH值、血乳酸的变化，以及14 d病死率。结果 治疗前两组患者动脉血气pH值、血清乳酸比较差异无统计学意义（P＞0.05），具有可比性。治疗48 h后，两组患者动脉血气pH值、血清乳酸均较本组治疗前有改善（P=0.000）；在治疗24h时，动脉血气pH值、血清乳酸变化两组比较差异无统计学意义（tpH=0.463，PpH=0.504；t乳酸=0.249，P乳酸=0.623）；但在治疗48h时，两组间血清乳酸比较差异有统计学意义（t组间=4.881，P组间=0.038）。结论 高置换量CVVH与低置换量CVVH均可有效地清除乳酸性酸中毒患者体内蓄积的乳酸，纠正酸碱失衡状态，但两组临床效果并无明显差异。

Objective The study aimed to assess the results from two cures of using different volume sizes which are high-volume （HV） and standard-volume （SV） of continuous venovenous hemofiltration （CVVH） for chronic renal failure （CRF） patients with lactic acidosis （LA）.Methods Adopting the method of prospective randomized control, 24 of CRF with LA cases from nephrology department of the 211 Hospital of the People′s Liberation Army from July 2016 to June 2017 were picked and moreover divided into the two groups mentioned above based on the random number table method. On the basis of conventional comprehensive treatment, the two groups of cases were cured for 48 h continuously with 35 mL/（kg·h） （SV） and 65 mL/（kg·h） （HV）, respectively. The variation of arterial blood gas pH before, 24 h after-and 48 h after-curation, the concentration of serum lactate of the two groups and death cases in 14 days were monitored and compared.Results Before the treatment, the two groups had comparability in pH value and concentration of serum lactate in which there were no significant differences. After the treatment, pH value and concentration of serum lactate in two groups were significantly improved（P=0.00）.After 24h-treatment, the changes of pH value and concentration of serum lactate were not obvious （tpH=0.463；PpH=0.504；t乳酸=0.249；P乳酸=0.623）; after 48 h-treatment, the changes of concentration of serum lactate in the two groups were prominent （t组间=4.881，P组间=0.038）. Conclusion Both HV-CVVH and SV-CVVH are effective for eliminating the lactate in CRF patients with lactic acidosis and rectifying acid-hase disturbance. However, there are no significant differences between them in clinical benefits and reducing mortality （P〉0.05）. This provides the reasonable CVVH therapeutic scheme for the chornic real failure with lactic acidosis.