临床干货:IgA肾病怎样使用激素?

2020-07-27 李青大夫 肾病科普

IgA肾病是我国最常见的一类肾小球肾炎,也是目前我国尿毒症的第一大原因。IgA肾病大多因为反复的呼吸道、尿道、肠道感染诱发,好发于青壮年,主要表现为血尿、蛋白尿和高血压。

IgA肾病是我国最常见的一类肾小球肾炎,也是目前我国尿毒症的第一大原因。IgA肾病大多因为反复的呼吸道、尿道、肠道感染诱发,好发于青壮年,主要表现为血尿、蛋白尿和高血压。

IgA肾病不是细菌感染直接损害肾脏,而是感染后诱发了自身免疫导致的肾损伤,所以治疗往往需要使用激素或者联合免疫抑制剂。

关于IgA肾病的治疗,多个指南大同小异,结合尿蛋白定量和肾功能,基本的治疗建议是:

1、肾功能正常的IgA肾病:如果尿蛋白定量<1.0g/d,应该使用沙坦类或者普利类降压药。

这两类药除了降压之外,还有降尿蛋白和肾脏保护作用,是慢性肾炎尤其是合并蛋白尿者的基础用药。不过,降尿蛋白所需的药量要大于降压所需的药量,教科书推荐可以用到降压药量的2~4倍。临床一般这样掌握:只要血压不低,应该用到能耐受的最大剂量。

这两类药只能选择一种,不能合用。

2、如果尿蛋白定量超过1.0g/d,而且肾功能正常的话,应该在沙坦类或者普利类降压药的基础上,使用激素治疗。

3、如果尿蛋白定量超过1.0g/d,但是肾功能下降(肾小球滤过率<60ml/min)的话,应该在沙坦类或者普利类降压药和激素的基础上,联合免疫抑制剂治疗,比如环磷酰胺、环孢素、他克莫司等。

环磷酰胺是一种传统的免疫抑制剂,尽管后来有许多免疫抑制剂问世,但环磷酰胺仍是疗效最稳定的免疫抑制剂之一。

环磷酰胺有口服片剂,也有静脉针剂,他用的应该是针剂,每只0.2g。

环磷酰胺口服:每次50~100mg,2次/日,连用4~6周;静点:每次0.6~0.8克,每2周1次,总量不超过0.1~0.15g/kg。观察发现,静点比口服副作用更小,疗效更好。所以大多选择静脉点滴使用。

环磷酰胺抑制性腺发育,未成熟男性应避免使用。

其他的肾小球肾炎,激素使用的起点是尿蛋白定量≥3.5g/d,那为什么IgA肾病尿蛋白定量大于等于1.0g/d就要使用激素呢?

因为相对于其他类型的肾小球肾炎,IgA肾病更容易发展到肾衰竭。据统计,大约20%~40%的IgA患者进展至终末期肾病(尿毒症),所以更要积极的治疗。

那IgA肾病怎样使用激素呢?

上述已经明确了IgA肾病激素使用的适应症,但是,不是所有的情况都可以使用激素。

1、激素使用的禁忌症和相对禁忌症

禁忌症:

活动性消化性溃疡;

肝硬化和门脉高压引起的消化道大出血;

新近接受胃肠吻合术。

相对禁忌症:

有以下情况时可以用,但应严格掌握指征:

严重感染(病毒、细菌、真菌和结核等);

严重的骨质疏松

严重糖尿病

严重高血压;

精神病;

青光眼;

病毒性肝炎。

2、选择哪一种激素?

根据药效维持时间,激素分长效激素(比如低塞米松)、短效激素(比如氢化考的松)和中效激素。治疗慢性自身免疫性疾病,既不用长效,也不用短效,而是选择中效激素。常用的中效激素有两种,泼尼松和甲泼尼龙,相对而言,甲泼尼龙的副作用更小一些。

3、激素的用法

激素的具体用法是:

泼尼松0.5~1mg/kg/日,或者甲泼尼龙0.8mg/kg/日,持续给药6~8周后,剂量开始递减,具体方法是,每2周减一片,等减到明天4片时,减量的节奏要减慢,比如每月减一片。减量至每日或隔日1~2片时维持,总疗程为 6 个月或更长时间。

近来有研究发现,小剂量激素与足剂量激素的远期疗效没有明显差异,但感染的风险减少,所以越来越多的使用小剂量激素:泼尼松0.5mg/kg/日,或者甲泼尼龙0.4mg/kg/日。

4、激素服用时间

清晨一次顿服,不推荐一天两次给药。

清晨是自身糖皮质激素的分泌高峰时间,此时,通过负反馈调节,下丘脑和垂体的分泌受抑制。此时服药,对下丘脑-垂体-肾上腺内分泌轴的影响最小。

5、激素副作用的应对策略

激素因为抑制免疫,容易诱发感染。所以使用激素前一定要排除慢性感染尤其是结核的存在。使用过程中一定要预防感染,并密切观察有没有感染症状。

关于激素诱发感染的问题,有两个“绝不”的原则:绝不预防使用抗菌素;一旦出现感染,使用抗菌素绝不手软。

激素导致钙丢失,哪怕使用一片激素,也要同时服用钙制剂比如钙尔奇D。

激素导致脂肪重新分布,引起向心性肥胖,面部、身体胖而胳膊、腿细,我们形容为“满月脸、水牛背”。这是许多人尤其是女士不愿意使用激素的主要原因,目前除了控制饮食外,没有更好的应对措施。

此外,激素引起食欲增加、失眠、糖尿病、高血压、胃溃疡等,一旦出现,需要对症处理。

再说这位粉丝的用药。

他的体重73kg,根据计算,泼尼松用量应该为每天35~70mg,或者甲泼尼龙用量每天28~56mg,相当于7~14片激素。

为了避免感染的发生,现在一般不超过每天每天12片激素,当然,在指南允许的范围内,经治医生可以灵活掌握。医生给他用每天50mg激素(相当于泼尼松10片),剂量是没有问题的。他的尿蛋白已经转阴,事实证明,治疗效果是不错的。

他的肾功能是正常的,环磷酰胺可以不用。

他用的代文是缬沙坦的原研药,每粒80mg。他现在已经用到每天2倍的剂量,蛋白尿已经转阴,血压已经达标,可以不再加量。

只有一少部分IgA肾炎发展到尿毒症,大部分患者经过合理的治疗,病情常年保持稳定。

不要乱用药。

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  1. [GetPortalCommentsPageByObjectIdResponse(id=921656, encodeId=424f92165628, content=尿液检测结果隐血+3(144),没有蛋白质的如何用药?, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b815457460, createdName=ms8000000847399112, createdTime=Sun Jan 31 11:48:46 CST 2021, time=2021-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=900118, encodeId=12d190011813, content=总结的好, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d37a5431276, createdName=ms9000000231985974, createdTime=Wed Nov 18 10:13:14 CST 2020, time=2020-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=893856, encodeId=21a0893856ec, content=好啊!!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201022/94bc90bf9c1648a79219a35a6e3e71b4/cbaeac86de0341e9a4b8a5ac6e3c709e.jpg, createdBy=8b795288851, createdName=1485bc56m93暂无昵称, createdTime=Thu Oct 22 22:38:40 CST 2020, time=2020-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805002, encodeId=b95380500248, content=写得蛮好, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200729/b72aca73e441491db6b1ae946b4adf2e/9cb3a853e76a4072b3b60609aa703649.jpg, createdBy=69bd5400778, createdName=ms5000000186581302, createdTime=Wed Jul 29 07:43:58 CST 2020, time=2020-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414607, encodeId=1cca141460e5b, content=<a href='/topic/show?id=c83e94827d' target=_blank style='color:#2F92EE;'>#IgA肾病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9482, encryptionId=c83e94827d, topicName=IgA肾病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cd7c3073380, createdName=huiwelcome, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503953, encodeId=7807150395368, content=<a href='/topic/show?id=641d94e7eb' target=_blank style='color:#2F92EE;'>#IgA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9477, encryptionId=641d94e7eb, topicName=IgA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c23f9697922, createdName=yibei, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=)]
    2021-01-31 ms8000000847399112

    尿液检测结果隐血+3(144),没有蛋白质的如何用药?

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=921656, encodeId=424f92165628, content=尿液检测结果隐血+3(144),没有蛋白质的如何用药?, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b815457460, createdName=ms8000000847399112, createdTime=Sun Jan 31 11:48:46 CST 2021, time=2021-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=900118, encodeId=12d190011813, content=总结的好, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d37a5431276, createdName=ms9000000231985974, createdTime=Wed Nov 18 10:13:14 CST 2020, time=2020-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=893856, encodeId=21a0893856ec, content=好啊!!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201022/94bc90bf9c1648a79219a35a6e3e71b4/cbaeac86de0341e9a4b8a5ac6e3c709e.jpg, createdBy=8b795288851, createdName=1485bc56m93暂无昵称, createdTime=Thu Oct 22 22:38:40 CST 2020, time=2020-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805002, encodeId=b95380500248, content=写得蛮好, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200729/b72aca73e441491db6b1ae946b4adf2e/9cb3a853e76a4072b3b60609aa703649.jpg, createdBy=69bd5400778, createdName=ms5000000186581302, createdTime=Wed Jul 29 07:43:58 CST 2020, time=2020-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414607, encodeId=1cca141460e5b, content=<a href='/topic/show?id=c83e94827d' target=_blank style='color:#2F92EE;'>#IgA肾病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9482, encryptionId=c83e94827d, topicName=IgA肾病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cd7c3073380, createdName=huiwelcome, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503953, encodeId=7807150395368, content=<a href='/topic/show?id=641d94e7eb' target=_blank style='color:#2F92EE;'>#IgA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9477, encryptionId=641d94e7eb, topicName=IgA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c23f9697922, createdName=yibei, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=)]
    2020-11-18 ms9000000231985974

    总结的好

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=921656, encodeId=424f92165628, content=尿液检测结果隐血+3(144),没有蛋白质的如何用药?, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b815457460, createdName=ms8000000847399112, createdTime=Sun Jan 31 11:48:46 CST 2021, time=2021-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=900118, encodeId=12d190011813, content=总结的好, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d37a5431276, createdName=ms9000000231985974, createdTime=Wed Nov 18 10:13:14 CST 2020, time=2020-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=893856, encodeId=21a0893856ec, content=好啊!!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201022/94bc90bf9c1648a79219a35a6e3e71b4/cbaeac86de0341e9a4b8a5ac6e3c709e.jpg, createdBy=8b795288851, createdName=1485bc56m93暂无昵称, createdTime=Thu Oct 22 22:38:40 CST 2020, time=2020-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805002, encodeId=b95380500248, content=写得蛮好, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200729/b72aca73e441491db6b1ae946b4adf2e/9cb3a853e76a4072b3b60609aa703649.jpg, createdBy=69bd5400778, createdName=ms5000000186581302, createdTime=Wed Jul 29 07:43:58 CST 2020, time=2020-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414607, encodeId=1cca141460e5b, content=<a href='/topic/show?id=c83e94827d' target=_blank style='color:#2F92EE;'>#IgA肾病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9482, encryptionId=c83e94827d, topicName=IgA肾病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cd7c3073380, createdName=huiwelcome, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503953, encodeId=7807150395368, content=<a href='/topic/show?id=641d94e7eb' target=_blank style='color:#2F92EE;'>#IgA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9477, encryptionId=641d94e7eb, topicName=IgA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c23f9697922, createdName=yibei, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=)]
    2020-10-22 1485bc56m93暂无昵称

    好啊!!!

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=921656, encodeId=424f92165628, content=尿液检测结果隐血+3(144),没有蛋白质的如何用药?, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b815457460, createdName=ms8000000847399112, createdTime=Sun Jan 31 11:48:46 CST 2021, time=2021-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=900118, encodeId=12d190011813, content=总结的好, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d37a5431276, createdName=ms9000000231985974, createdTime=Wed Nov 18 10:13:14 CST 2020, time=2020-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=893856, encodeId=21a0893856ec, content=好啊!!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201022/94bc90bf9c1648a79219a35a6e3e71b4/cbaeac86de0341e9a4b8a5ac6e3c709e.jpg, createdBy=8b795288851, createdName=1485bc56m93暂无昵称, createdTime=Thu Oct 22 22:38:40 CST 2020, time=2020-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805002, encodeId=b95380500248, content=写得蛮好, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200729/b72aca73e441491db6b1ae946b4adf2e/9cb3a853e76a4072b3b60609aa703649.jpg, createdBy=69bd5400778, createdName=ms5000000186581302, createdTime=Wed Jul 29 07:43:58 CST 2020, time=2020-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414607, encodeId=1cca141460e5b, content=<a href='/topic/show?id=c83e94827d' target=_blank style='color:#2F92EE;'>#IgA肾病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9482, encryptionId=c83e94827d, topicName=IgA肾病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cd7c3073380, createdName=huiwelcome, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503953, encodeId=7807150395368, content=<a href='/topic/show?id=641d94e7eb' target=_blank style='color:#2F92EE;'>#IgA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9477, encryptionId=641d94e7eb, topicName=IgA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c23f9697922, createdName=yibei, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=)]
    2020-07-29 ms5000000186581302

    写得蛮好

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=921656, encodeId=424f92165628, content=尿液检测结果隐血+3(144),没有蛋白质的如何用药?, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b815457460, createdName=ms8000000847399112, createdTime=Sun Jan 31 11:48:46 CST 2021, time=2021-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=900118, encodeId=12d190011813, content=总结的好, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d37a5431276, createdName=ms9000000231985974, createdTime=Wed Nov 18 10:13:14 CST 2020, time=2020-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=893856, encodeId=21a0893856ec, content=好啊!!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201022/94bc90bf9c1648a79219a35a6e3e71b4/cbaeac86de0341e9a4b8a5ac6e3c709e.jpg, createdBy=8b795288851, createdName=1485bc56m93暂无昵称, createdTime=Thu Oct 22 22:38:40 CST 2020, time=2020-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805002, encodeId=b95380500248, content=写得蛮好, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200729/b72aca73e441491db6b1ae946b4adf2e/9cb3a853e76a4072b3b60609aa703649.jpg, createdBy=69bd5400778, createdName=ms5000000186581302, createdTime=Wed Jul 29 07:43:58 CST 2020, time=2020-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414607, encodeId=1cca141460e5b, content=<a href='/topic/show?id=c83e94827d' target=_blank style='color:#2F92EE;'>#IgA肾病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9482, encryptionId=c83e94827d, topicName=IgA肾病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cd7c3073380, createdName=huiwelcome, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503953, encodeId=7807150395368, content=<a href='/topic/show?id=641d94e7eb' target=_blank style='color:#2F92EE;'>#IgA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9477, encryptionId=641d94e7eb, topicName=IgA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c23f9697922, createdName=yibei, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=921656, encodeId=424f92165628, content=尿液检测结果隐血+3(144),没有蛋白质的如何用药?, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=7b815457460, createdName=ms8000000847399112, createdTime=Sun Jan 31 11:48:46 CST 2021, time=2021-01-31, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=900118, encodeId=12d190011813, content=总结的好, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d37a5431276, createdName=ms9000000231985974, createdTime=Wed Nov 18 10:13:14 CST 2020, time=2020-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=893856, encodeId=21a0893856ec, content=好啊!!!, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201022/94bc90bf9c1648a79219a35a6e3e71b4/cbaeac86de0341e9a4b8a5ac6e3c709e.jpg, createdBy=8b795288851, createdName=1485bc56m93暂无昵称, createdTime=Thu Oct 22 22:38:40 CST 2020, time=2020-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805002, encodeId=b95380500248, content=写得蛮好, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200729/b72aca73e441491db6b1ae946b4adf2e/9cb3a853e76a4072b3b60609aa703649.jpg, createdBy=69bd5400778, createdName=ms5000000186581302, createdTime=Wed Jul 29 07:43:58 CST 2020, time=2020-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1414607, encodeId=1cca141460e5b, content=<a href='/topic/show?id=c83e94827d' target=_blank style='color:#2F92EE;'>#IgA肾病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9482, encryptionId=c83e94827d, topicName=IgA肾病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=cd7c3073380, createdName=huiwelcome, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503953, encodeId=7807150395368, content=<a href='/topic/show?id=641d94e7eb' target=_blank style='color:#2F92EE;'>#IgA#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9477, encryptionId=641d94e7eb, topicName=IgA)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c23f9697922, createdName=yibei, createdTime=Tue Jul 28 17:04:32 CST 2020, time=2020-07-28, status=1, ipAttribution=)]
    2020-07-28 yibei