指南共识丨肝硬化低钠血症及腹水其他并发症(肝性胸水、腹疝)的处理

2022-01-19 杨力 江西省景德镇市第三人民医院消化内科 消化界

肝硬化择期疝修补术最好在腹水得到控制并且患者的整体状况(包括营养状况)得到优化之后,通过多学科方法进行。

译者注:本稿全文翻译自美国肝病研究学会官方期刊Hepatology 2021年在线发表的文献“Diagnosis,Evaluation,and Management of Ascites and Hepatorenal Syndrome”,以供消化及肝病同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声明进行了翻译并对全文排版,在此一并致谢!

低钠血症

肝硬化腹水患者低钠血症的评估

低钠血症定义为血清钠浓度≤135 mmol/L,近一半(49%)的肝硬化腹水患者存在低钠血症,超过1/5(22%)的血清钠水平≤130 mmol/L[113]。大多数肝硬化腹水患者的低钠血症为高血容量性低钠血症,然而,也应考虑到低血容量和正常血容量性低钠血症的可能。由于经口服摄入不足,或过度利尿或泻药治疗相关的尿液或胃肠道损失,可发生低血容量性低钠血症。正常血容量性低钠血症在肝硬化患者中并不常见,除非有特定原因如抗利尿激素分泌不当综合征、药物(如舍曲林、卡马西平)和严重的甲状腺功能减退或肾上腺功能不全。

低钠血症的症状在肝硬化患者中并不常见,包括恶心、肌肉痉挛、步态不稳、嗜睡、头痛、头晕、意识模糊和癫痫发作。低钠血症的改善与脑水肿减轻、认知改善和生活质量提高[114]以及复杂信息处理能力改善[115]相关。

肝硬化低钠血症按照严重程度可分为,轻度(126-135 mmol/L)、中度(120-125mmol/L) 和重度(<120mmol/L)。轻度低钠血症除了监测和限水外,通常不需要特殊管理。然而,有症状的低钠血症、中度或重度低钠血症以及即将行肝移植(LT)的患者需要特殊处理。

低钠血症反映肝硬化进展时血流动力学状态恶化(图1)。血Na≤130 mmol/L的肝硬化患者发生肝性脑病(OR 3.4)、HRS(OR 3.5)和 SBP(OR 2.4)[113]的风险增加,住院死亡率[86]和在等候名单中的死亡率[98,100,101]也较高。即使是轻度低钠血症(血Na 131-135 mmol/L)的患者,这些严重并发症的风险也增加[113]。这一发现促使美国于2016年将血清钠纳入到肝脏分配系统,从而为低钠血症患者提供肝移植[99]

肝硬化腹水患者低钠血症的管理

肝硬化腹水患者低钠血症的治疗取决于病因、病程、严重程度和紧迫性。肝硬化中急性低钠血症(48 h内发作)较慢性低钠血症少见,急性低钠血症患者可以而且通常应该迅速纠正低钠血症以预防脑水肿,而不必担心渗透性脱髓鞘综合征(ODS)。慢性低钠血症患者需要逐渐并有节制地纠正,避免过度纠正,以降低ODS的风险。对于低血容量性低钠血症,应停用利尿剂和(或)泻药,进行液体复苏,通常使用5%静脉白蛋白或晶体(优选乳酸林格氏液)溶液。正常血容量性低钠血症应根据具体的潜在原因进行管理。

高容量性低钠血症的治疗包括限制液体摄入、减少或停用利尿剂和泻药、使用高渗白蛋白和(或)加压素受体拮抗剂(“普坦”类)[116-122]。一项纳入595例肝硬化低钠血症患者的观察性研究显示,低钠血症的治疗变化很大且经常无效,纠正后55%的患者复发[116]。仅有36%的中度和重度低钠血症患者通过3天液体限制使血钠增加≥5mmol/L,而71%的托伐普坦治疗患者和78%的高渗盐水治疗患者达到了这个终点[116]

尽管液体限制可以增加血钠,或限制血钠水平的进一步下降,但患者的耐受性和依从性是重要的障碍。仅通过限制液体以提高血钠,需要将摄入量减少到低于尿量和隐性丢失的总和,在肝硬化患者中这通常意味着液体摄入量<750 mL/d[118]。长时间将入液量限制在此水平,患者耐受性非常差,可导致总体营养摄入量减少。在肝硬化人群普坦类药物试验的对照组中,液体限制为1500 mL/d[123]和1000 mL/d[124]时,低钠血症稳定,特别是在使用利尿剂的患者中[124]。一项纳入住院肝硬化患者的大样本观察性队列研究显示,输注白蛋白可改善低钠血症[117]。因此,推荐在中度低钠血症(120-125 mmol/L)管理中尝试限制液体至1000 mL/d,严重低钠血(<120 mmol/L)推荐更严格的液体限制并且输注白蛋白。纠正低钾血症通过改善细胞Na-K交换,有助于纠正低钠血症。

普坦类药物可有效提高血钠,但它们的作用短暂。在一项研究中,仅有少数(22%)患者在整个治疗过程中持续血钠增加>130 mmol/L[121]。而在另一项研究中,托伐普坦停药7天后低钠血症复发[122]。重要的是,美国食品和药物管理局限制托伐普坦的治疗时间为30天,并有与严重肝细胞损伤风险相关的“黑框”警告,这部分是来自多囊肾病患者的数据[125],而在肝硬化患者中并未发现肝毒性[119]。因此,在考虑风险和收益后,在肝硬化中谨慎使用普坦类药物是合理的。

高渗盐水可纠正血钠,但往往会导致血容量过多和腹水恶化,仅用于有症状或严重低钠血症患者或即将行LT患者的短期治疗。当LT前使用高渗盐水时,可能需要围术期或术中肾脏替代疗法(RRT)以控制血容量过多[126]。是否继续进行LT,则必须根据移植的紧迫性、低钠血症的严重程度和当地的专业经验个体化抉择。接受LT的低钠血症患者术后并发症风险增加,包括感染、肾功能衰竭和ODS[126-130]。ODS在LT中很少见,受者中的发生率为0.5%~1.5%[131-135]。术中大量使用含钠物品如浓缩红细胞和新鲜冰冻血浆以及盐水溶液,可能会使血钠升高过快。ODS的典型病程在快速纠正血钠后2~7天开始,患者表现为癫痫发作或脑病,随后短期改善,随后出现构音障碍、吞咽困难、动眼神经功能障碍和四肢轻瘫的临床恶化[136]。ODS可通过体格检查和脑部磁共振成像来诊断[127,137]

ODS可能更常见于晚期肝病、酒精中毒、更严重的低钠血症、营养不良、严重代谢紊乱(低磷血症、低钾血症或低血糖)、低胆固醇和既往有脑病的患者[133-135]。ODS的风险可通过多学科、协调护理来降低,无需仅仅因低钠血症而禁行LT[126,127]。美国的一个专家小组推荐一般ODS风险患者血钠的目标变化率为每天4~8 mmol/L,24 h不超过10~12 mmol/L,对于ODS高风险患者(包括晚期肝病患者),目标值降低为每天4~6 mmol/L,每24 h不超过8 mmol/L[118]。如果发生过度纠正,可以考虑使用无电解质水或去氨加压素重新降低血钠[118]。使用氨丁三醇[也称为三(羟甲基)氨基甲烷]可降低ODS风险[126,138]

指南声明

●  无症状的肝硬化轻度低钠血症(血钠浓度126-135 mmol/L),除监测和限水之外,无需特殊处理。

●  中度低钠血症(120-125 mmol/L)推荐限水(1000 mL/d)并停用利尿剂,严重低钠血症(<120 mmol/L)推荐更严格地限制水摄入并输注白蛋白。

●  肝硬化使用加压素受体拮抗剂在治疗期间可升高血钠浓度,但仅限短期(≤30 天)内谨慎使用。

●  高渗盐水仅短期用于有症状或严重低钠血症患者或即将行LT的患者。

●  当肝硬化患者需要纠正慢性低钠血症时,血清(Na)升高的目标速率为每24 h 4~6 mmol/L,每24 h不超过8 mmol/L,以降低渗透性脱髓鞘综合征(ODS)风险。 

●  LT时严重低钠血症(<120 mmol/L)增加LT的ODS风险。多学科协调护理可降低ODS风险。

肝性胸水

肝性胸水(HH)是在门静脉高压中发生的漏出性胸腔积液。肝硬化HH的发生率为4%~12% [139-142],通常是单侧的。一项纳入77例HH患者的研究中,73%的HH在右侧,17%在左侧,10%为双侧,9%无临床腹水[143]。在HH中,胸腔积液起源于腹腔,吸气时胸腔内负压使得液体通过膈裂孔进入胸腔[141]。血清与胸水白蛋白梯度>1.1 g/dL提示HH[143]。应考虑到由感染、胰腺炎、恶性肿瘤或心肺原因引起的胸腔积液,特别是当血清与胸水白蛋白梯≤1.1 g/dL、左侧积液或无腹水时。HH 中的胸水蛋白含量可高于并发的腹水,这可能与静水压力梯度有关。

HH患者预后不良,其死亡风险超过MELD评分预测的风险,应考虑行LT[143,144]。HH住院后90天死亡率为74%,尽管其平均 MELD为14,后者预测90天死亡率仅为6%~8%[143]。HH并发症包括自发性细菌性脓胸 (SBE)、进行性呼吸衰竭、肺受压和胸腔穿刺术并发症如气胸和出血[144]

HH的初始管理类似于腹水,限制钠盐和利尿剂。如果存在腹水,LVP 与静脉白蛋白可改善通气功能,但通常也需要胸腔穿刺术。无需输注血小板或血浆即可进行胸腔穿刺术[145]。没有数据可以指导清除胸腔积液的上限值。胸腔穿刺术后液体会迅速积聚,因此通常需要重复胸腔穿刺术[146]

顽固性或复发性HH最好行TIPS 或LT治疗[147-150]。基于其死亡率增加,符合标准的HH患者给予额外的LT优先权(表8)[151]。间歇性输注白蛋白在这一人群的治疗作用尚无数据,然而,如果输注白蛋白可以改善腹水控制,那么HH也可能受益。HH患者放置胸管与高发病率、临床恶化导致死亡、或需要紧急TIPS或LT[152-154]以及瘘管的发生相关,应该避免。近期,有报道留置隧道式胸腔导管的并发症发生率较低(感染4.5%;液体再蓄积20%;自发性胸膜固定术31%),可谨慎考虑作为重复胸腔穿刺术的替代方法[155]。经常通过留置胸腔导管清除胸腔积液的患者,有发生蛋白质消耗和营养不良的风险。化学胸膜固定术通常会导致局部液体积聚,不推荐使用。已有报道应用视频辅助胸腔镜手术修复膈肌缺损[156]

指南声明

●  HH的首选治疗包括饮食限钠和利尿剂,以及必要时行胸腔穿刺术。

●  在部分经选择的患者,TIPS可考虑作为顽固性HH的二线治疗。

●  HH应避免胸腔置管,但在仔细筛选的对药物治疗无应答且不适合TIPS 的患者,可考虑留置隧道式导管。

●  HH患者应考虑LT。

腹疝

腹壁疝和腹股沟疝常见于肝硬化腹水患者,大约20%的肝硬化患者会出现脐疝[158]。腹水引起的腹内压增加、腹肌减弱和营养不良可导致疝迅速扩大。相反,最佳的液体控制、适当的营养和使用粘合剂的保守管理可以最大限度减少或防止疝的发生和进展。疝可表现为嵌顿、压迫性坏死、破裂、内脏和腹膜炎。腹水量(例如 LVP)快速下降可导致嵌顿[159-161]

 

符合在近期内行LT条件的患者,应将疝修补术推迟到移植期间或之后[162]。无迫切肝移植需求(即低MELD)的患者,在仔细考虑风险和益处(与非手术管理比较)之后,对于可能需要紧急手术的特定患者可行择期疝修补术[163-166]。在择期疝修补术之前应控制临床明显的腹水,首选腹腔镜手术[167]。补片的使用可降低复发率,但可能增加感染和其他并发症的风险[167]。术后控制腹水和优化营养是成功的关键决定因素,术后钠摄入量应限制在2 g/d(90 mmol/d),停止或最小化静脉维持输液。发生疝相关并发症风险高的RA患者,在外科手术之前,可以考虑择期术前TIPS[168]。包括考虑TIPS置入在内的多学科方法,已使嵌顿或自发性破裂疝的手术死亡率降低至5%[168]

肝硬化RA患者脐疝绞窄或破裂的急诊手术,最好由在肝硬化患者护理经验丰富的外科医生实施,并与肝病专家协商以便术后控制腹水,这对于伤口愈合和预防继发性细菌性腹膜炎是必要的。在这种情况下,如果无法通过药物控制腹水,可以考虑在术后期间行TIPS置入。

指南声明

●  肝硬化择期疝修补术最好在腹水得到控制并且患者的整体状况(包括营养状况)得到优化之后,通过多学科方法进行。

●  肝硬化腹水未控制的患者,在择期疝修补术前或急诊手术后应考虑行TIPS。

编辑注:为方便读者对照原文,本文的参考文献和图表序号按原顺序标注,不重新编号。

(参考文献备索)

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attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2023-03-29 李洪520 来自河北省

    学习了,正好有个病例

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=2122520, encodeId=48d8212252031, content=学习了,正好有个病例, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLiaB0iaEcgjgpwAktr7UdLtlr3GctcIT0lod9ku49LdicibcibKUkBfwqJEoeWNLeTsiamoxeiccialvapXw/132, createdBy=21752501008, createdName=李洪520, createdTime=Wed Mar 29 17:32:15 CST 2023, time=2023-03-29, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=1758411, encodeId=e1741e5841195, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2022-10-07 丁鹏鹏
  3. [GetPortalCommentsPageByObjectIdResponse(id=2122520, encodeId=48d8212252031, content=学习了,正好有个病例, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLiaB0iaEcgjgpwAktr7UdLtlr3GctcIT0lod9ku49LdicibcibKUkBfwqJEoeWNLeTsiamoxeiccialvapXw/132, createdBy=21752501008, createdName=李洪520, createdTime=Wed Mar 29 17:32:15 CST 2023, time=2023-03-29, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=1758411, encodeId=e1741e5841195, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2022-09-07 ms4000000835034751

    学习了

    0

  4. 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createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2022-02-22 634799236

    学习了

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=2122520, encodeId=48d8212252031, content=学习了,正好有个病例, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLiaB0iaEcgjgpwAktr7UdLtlr3GctcIT0lod9ku49LdicibcibKUkBfwqJEoeWNLeTsiamoxeiccialvapXw/132, createdBy=21752501008, createdName=李洪520, createdTime=Wed Mar 29 17:32:15 CST 2023, time=2023-03-29, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=1758411, encodeId=e1741e5841195, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2022-01-21 SR~young海东

    坚持学习

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=2122520, encodeId=48d8212252031, content=学习了,正好有个病例, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLiaB0iaEcgjgpwAktr7UdLtlr3GctcIT0lod9ku49LdicibcibKUkBfwqJEoeWNLeTsiamoxeiccialvapXw/132, createdBy=21752501008, createdName=李洪520, createdTime=Wed Mar 29 17:32:15 CST 2023, time=2023-03-29, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=1758411, encodeId=e1741e5841195, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
  7. [GetPortalCommentsPageByObjectIdResponse(id=2122520, encodeId=48d8212252031, content=学习了,正好有个病例, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLiaB0iaEcgjgpwAktr7UdLtlr3GctcIT0lod9ku49LdicibcibKUkBfwqJEoeWNLeTsiamoxeiccialvapXw/132, createdBy=21752501008, createdName=李洪520, createdTime=Wed Mar 29 17:32:15 CST 2023, time=2023-03-29, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=1758411, encodeId=e1741e5841195, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
  8. [GetPortalCommentsPageByObjectIdResponse(id=2122520, encodeId=48d8212252031, content=学习了,正好有个病例, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLiaB0iaEcgjgpwAktr7UdLtlr3GctcIT0lod9ku49LdicibcibKUkBfwqJEoeWNLeTsiamoxeiccialvapXw/132, createdBy=21752501008, createdName=李洪520, createdTime=Wed Mar 29 17:32:15 CST 2023, time=2023-03-29, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=1758411, encodeId=e1741e5841195, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2022-01-21 zz12341238
  9. [GetPortalCommentsPageByObjectIdResponse(id=2122520, encodeId=48d8212252031, content=学习了,正好有个病例, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLiaB0iaEcgjgpwAktr7UdLtlr3GctcIT0lod9ku49LdicibcibKUkBfwqJEoeWNLeTsiamoxeiccialvapXw/132, createdBy=21752501008, createdName=李洪520, createdTime=Wed Mar 29 17:32:15 CST 2023, time=2023-03-29, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=1758411, encodeId=e1741e5841195, content=<a href='/topic/show?id=84ba49031f9' target=_blank style='color:#2F92EE;'>#并发#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=49031, encryptionId=84ba49031f9, topicName=并发)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2022-01-21 yx1156

    很好的论文!

    0

  10. 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createdBy=a27e37327108, createdName=丁鹏鹏, createdTime=Fri Oct 07 15:38:01 CST 2022, time=2022-10-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1247703, encodeId=9dea124e70327, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=42b38312608, createdName=ms4000000835034751, createdTime=Wed Sep 07 15:56:30 CST 2022, time=2022-09-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1196222, encodeId=7c7211962227f, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTLfy3flRicYVgfIr6WafJSNfCXltQBCgoo5pkvHRcjO4xcNXzh1t6WZvGj7eQia6AHHv6fIGDpsHb6g/132, createdBy=41072558982, createdName=634799236, createdTime=Tue Feb 22 20:49:46 CST 2022, time=2022-02-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186960, encodeId=3552118696073, content=坚持学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210313/9df56058b3964a8cac82563f95f0389d/c1b478592e8e4463bef44d32712e98fd.jpg, createdBy=ea905324251, createdName=SR~young海东, createdTime=Fri Jan 21 20:08:46 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1361402, encodeId=3164136140210, content=<a href='/topic/show?id=835426385a6' target=_blank style='color:#2F92EE;'>#低钠血症#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26385, encryptionId=835426385a6, topicName=低钠血症)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c22f171, createdName=kord1982, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1517563, encodeId=7b9f151e56307, content=<a href='/topic/show?id=08dbe042428' target=_blank style='color:#2F92EE;'>#疝#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70424, encryptionId=08dbe042428, topicName=疝)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5b7011086586, createdName=ms4657536712156177, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1538291, encodeId=a17a153829125, content=<a href='/topic/show?id=1258263835a' target=_blank style='color:#2F92EE;'>#低钠#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=26383, encryptionId=1258263835a, topicName=低钠)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=8b9512951240, createdName=zz12341238, createdTime=Fri Jan 21 13:38:01 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186682, encodeId=bb101186682df, content=很好的论文!, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=58001397990, createdName=yx1156, createdTime=Fri Jan 21 07:30:04 CST 2022, time=2022-01-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1186328, encodeId=c8fd1186328ba, content=同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTIrrxxDxnLic8t6EAs38Qfwo6H2h6JMleIgb9OSYf6LMnVDkQEqUXWoSDWboibjhOBI9SJDTXweqQIA/132, createdBy=50aa5321359, createdName=查查佳佳, createdTime=Thu Jan 20 09:08:07 CST 2022, time=2022-01-20, status=1, ipAttribution=)]
    2022-01-20 查查佳佳

    同道临床参考,不当之处,敬请指正。另外,科室吴璋萱医师对指南声

    0