Eur Heart J:警惕心衰治疗中的“肾损伤”假象

2015-01-16 伊文 丁香园

肾损害在评估心衰患者预后方面具有十分重要的作用,研究显示,与肾功能正常的心衰患者相比,肾小球滤过率(GFR)降低的心衰患者死亡风险率显著升高,是前者的两倍,而且无论何种原因引发的 eGFR降低均与患者死亡率升高相关,增幅达 60%至 80%。 因此,越来越多的临床医生开始关注心衰患者的肾功能情况,但是如何鉴别诊断真正的心衰过程中的肾损伤尚需进一步讨论。 一、心衰肾功能定义问题多

肾损害在评估心衰患者预后方面具有十分重要的作用,研究显示,与肾功能正常的心衰患者相比,肾小球滤过率(GFR)降低的心衰患者死亡风险率显著升高,是前者的两倍,而且无论何种原因引发的 eGFR降低均与患者死亡率升高相关,增幅达 60%至 80%。

因此,越来越多的临床医生开始关注心衰患者的肾功能情况,但是如何鉴别诊断真正的心衰过程中的肾损伤尚需进一步讨论。

一、心衰肾功能定义问题多

1.“肾功能恶化”不统一

尽管多数心血管临床研究将这种 eGFR降低现象称为“肾功能恶化”(WRF),但是这些研究采取的 WRF定义规则五花八门。各个研究关注的肾功能标记物不统一,包括血肌酐、胱抑素 C、eGFR等,而且在“指标变化达到何种程度算是 WRF”这个问题上,各研究也无法“达成共识”。

2.“急性肾损伤”乱象

近年来,心血管疾病研究者从肾脏领域的研究引进了“急性肾损伤”(AKI)这个概念,并在 AKI定义中提到了患者血肌酐升高(或 eGFR降低)。事实上,AKI这个概念在许多心衰研究中被误用。

更麻烦的是,不同指南提供了不同的 AKI诊断标准,这些指南分别是 RIFLE、 AKIN及 KDIGO。多种标准往往导致临床医生在评估心衰患者肾功能时感到无所适从。

3. 临床医生低估了“心肾综合征”复杂性

无论心衰中患者基线肾功能受损还是其肾功能进行性恶化,临床都统称为“心肾综合征”,而我们并没有足够的证据支持两者确实存在病理生理学因果关系,或者说临床医生低估了“心肾综合征”病理上的复杂性。

事实上,不仅仅是心衰本身的充血等病理现象会影响患者肾功能,其服用的肾素 -血管紧张素 -醛固酮系统抑制剂等药物也会影响肾脏的自调作用,导致 GFR降低。一些并存疾病也会影响患者肾功能,例如长期动脉粥样硬化、高血压糖尿病均会导致病情复杂化。

因此,心肾综合征这个概念远比我们想象的复杂,我们不能仅仅通过简单评估某个或某几个指标就武断的给出结论(下文详述)。

二、血肌酐“以偏概全”现象

每个肾脏学会指南都将 AKI分为三期,即 RIFLE倡议的 “危险”、“损伤”及“衰竭”三个病情严重程度分级,AKIN及 KDIGO也给出了类似的 3期分级。

与 WRF的定义相似,AKI的病情分级以患者血肌酐为标准,即血肌酐水平越高,其 AKI严重程度越高。但是应用到心衰研究领域时,我们不能仅依靠血肌酐判断患者病情,还应考虑其他肾功能相关的重要因素。

1.慢性心衰的血肌酐时间悖论

各个指南对于血肌酐监测时间窗都有具体的要求,如 AKIN指南强调患者 48小时内血肌酐的变化,RIFLE指南要求 1至 7天内血肌酐变化且变化后肌酐水平维持时间超过 24小时。而且指南要求除了血肌酐之外,临床医生还要关注患者尿量情况。

在慢性心衰研究中,我们一般不会在这么短的时间内重复检测患者的血肌酐水平,因此,我们很难说掌握心衰过程中确切的 AKI发病率。虽然慢性心衰的长期病程容易使患者罹患 WRF,但是必须强调的是 WRF往往出现于血肌酐升高之后的一段时间,这意味着心衰其他方面的恶化或是 WRF的关键因素。

2.被夸大的急性心衰血肌酐

在急性心衰方面,血肌酐短期变化或许更有意义。但是,极少有急性心衰的研究关注患者尿量的具体变化以及尿量与患者 eGFR、血肌酐的相关性。退一步来看,即使研究者关注了患者尿量变化,心衰利尿药物治疗也会降低这一指标的可信性。

因此,对于急性心衰,即使患者符合最为常用的 WRF定义标准(血肌酐≥26.5μmol/L),这也仅仅意味患者处于 AKI“危险”期。而且只有在患者缺乏有效心衰治疗或缓解充血症状的情况下,这种 WRF才与患者死亡率升高相关。而急性心衰患者罹患 2或 3期 AKI的情况较罕见。

三、心衰中的“假性肾损伤”

那么,对于心衰中的肾功能损伤定义,我们心脏病学临床医生该何去何从呢?

首先,对于急性失代偿心衰患者,如果治疗成功,那么我们发现其血肌酐升高时不应武断的将其诊断为 AKI或WRF。虽然与肾脏病学的终点事件相同,但是心衰患者的肾功能损伤往往是由于间接因素导致的,因此,不能仅通过一个简单的血肌酐指标来确定心衰患者的肾功能情况。

1.“有益的”血肌酐升高

在临床治疗中,心衰患者充血症状缓解常伴随着血液浓稠度升高,与患者良性预后相关。虽然具体幅度不清楚,但是这种血管内血容积降低会导致血肌酐相对升高。

有研究指出慢性心衰患者服用服用的肾素 -血管紧张素 -醛固酮系统抑制剂造成的血肌酐升高与良好预后相关。对于急性心衰患者而言,伴随其症状及体重情况改善而出现的血肌酐升高与其不良预后无相关性。

2.假性 AKI

引入假性 AKI这一概念或许可以更好的解释心衰治疗过程中出现的疑似肾损伤现象,所谓的假性 AKI指的是心衰患者在其症状改善过程中出现的血肌酐升高,而其肾功能并未受损。

具体来说,临床医生需要结合心衰患者的具体临床表现,辅以肾功能标志物检测,确诊患者是 AKI,还是假性AKI。换言之,心衰患者的肾功能不仅仅取决于其血肌酐水平,更受到其心衰疾病背景的影响,而且后者的作用更为重要。

例如,Valente博士等人进行的一项研究显示,给予心衰患者利尿药物治疗后,WRF发生率最高的两个组分别是药物反应最好与最差的两个组。应用新观点,我们不难判断虽然两组患者血肌酐均升高,但是利尿药反应最好的小组无疑是假性 AKI,而最差组才是真正的 AKI。

还有一点需要强调的是,对于心衰患者来说,稳定的血肌酐水平是良性预后的有力预测因素,其预测能力远胜于血肌酐水平的变化。

四、结语

总而言之,我们在心衰治疗中不能单纯凭借患者血肌酐或 eGFR确诊其肾功能情况,适度血肌酐增高不一定是坏事。作为一个新观点,假性 AKI对心衰临床治疗意义重大,但依然需要研究检验其适用性。

原始出处:

Damman K1, Tang WH2, Testani JM3, McMurray JJ4.Terminology and definition of changes renal function in heart failure.Eur Heart J. 2014 Dec 21;35(48):3413-3416. Epub 2014 Aug 24.

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    2015-07-29 sundong

    0

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    2015-06-10 Messichen1992

    需要更多的文献帮助理解这个新观点

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=33762, encodeId=301833e62af, content=哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3ykRSkuxjt93yc9tvDWfIQItrwiaKSCps5kyrTyDlwic2FgoCWe88wR3ZiaggKYGueDIp26zVgnbzriaQ/0, createdBy=89d71602869, createdName=sundong, createdTime=Wed Jul 29 11:19:00 CST 2015, time=2015-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=26900, encodeId=ecda2690012, content=需要更多的文献帮助理解这个新观点, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed101627734, createdName=Messichen1992, createdTime=Wed Jun 10 16:08:00 CST 2015, time=2015-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20260, encodeId=9c5020260e9, content=AKI对心衰临床治疗意义重大,但依然需要研究检验其适用性, beContent=null, objectType=article, channel=null, level=null, likeNumber=129, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:25:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20259, encodeId=2a4020259bd, content=轻度肾脏疾病对母亲和婴儿可能会增加孕期风险, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:23:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=14572, encodeId=e04f145e226, content=AKI的诊断依据?很好的分析和诠释!, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76f6105517, createdName=Jiangyh0406, createdTime=Thu Jan 22 10:53:00 CST 2015, time=2015-01-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1355954, encodeId=117e135595498, content=<a href='/topic/show?id=b0702e84b9' target=_blank style='color:#2F92EE;'>#ART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2784, encryptionId=b0702e84b9, topicName=ART)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396892, encodeId=60d2139689235, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1562281, encodeId=010d15622819c, content=<a href='/topic/show?id=f69d864413' target=_blank style='color:#2F92EE;'>#HEART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8644, encryptionId=f69d864413, topicName=HEART)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=)]
    2015-04-11 x35042875

    AKI对心衰临床治疗意义重大,但依然需要研究检验其适用性

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=33762, encodeId=301833e62af, content=哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3ykRSkuxjt93yc9tvDWfIQItrwiaKSCps5kyrTyDlwic2FgoCWe88wR3ZiaggKYGueDIp26zVgnbzriaQ/0, createdBy=89d71602869, createdName=sundong, createdTime=Wed Jul 29 11:19:00 CST 2015, time=2015-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=26900, encodeId=ecda2690012, content=需要更多的文献帮助理解这个新观点, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed101627734, createdName=Messichen1992, createdTime=Wed Jun 10 16:08:00 CST 2015, time=2015-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20260, encodeId=9c5020260e9, content=AKI对心衰临床治疗意义重大,但依然需要研究检验其适用性, beContent=null, objectType=article, channel=null, level=null, likeNumber=129, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:25:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20259, encodeId=2a4020259bd, content=轻度肾脏疾病对母亲和婴儿可能会增加孕期风险, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:23:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=14572, encodeId=e04f145e226, content=AKI的诊断依据?很好的分析和诠释!, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76f6105517, createdName=Jiangyh0406, createdTime=Thu Jan 22 10:53:00 CST 2015, time=2015-01-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1355954, encodeId=117e135595498, content=<a href='/topic/show?id=b0702e84b9' target=_blank style='color:#2F92EE;'>#ART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2784, encryptionId=b0702e84b9, topicName=ART)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396892, encodeId=60d2139689235, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1562281, encodeId=010d15622819c, content=<a href='/topic/show?id=f69d864413' target=_blank style='color:#2F92EE;'>#HEART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8644, encryptionId=f69d864413, topicName=HEART)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=)]
    2015-04-11 x35042875

    轻度肾脏疾病对母亲和婴儿可能会增加孕期风险

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=33762, encodeId=301833e62af, content=哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3ykRSkuxjt93yc9tvDWfIQItrwiaKSCps5kyrTyDlwic2FgoCWe88wR3ZiaggKYGueDIp26zVgnbzriaQ/0, createdBy=89d71602869, createdName=sundong, createdTime=Wed Jul 29 11:19:00 CST 2015, time=2015-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=26900, encodeId=ecda2690012, content=需要更多的文献帮助理解这个新观点, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed101627734, createdName=Messichen1992, createdTime=Wed Jun 10 16:08:00 CST 2015, time=2015-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20260, encodeId=9c5020260e9, content=AKI对心衰临床治疗意义重大,但依然需要研究检验其适用性, beContent=null, objectType=article, channel=null, level=null, likeNumber=129, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:25:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20259, encodeId=2a4020259bd, content=轻度肾脏疾病对母亲和婴儿可能会增加孕期风险, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:23:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=14572, encodeId=e04f145e226, content=AKI的诊断依据?很好的分析和诠释!, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76f6105517, createdName=Jiangyh0406, createdTime=Thu Jan 22 10:53:00 CST 2015, time=2015-01-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1355954, encodeId=117e135595498, content=<a href='/topic/show?id=b0702e84b9' target=_blank style='color:#2F92EE;'>#ART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2784, encryptionId=b0702e84b9, topicName=ART)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396892, encodeId=60d2139689235, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1562281, encodeId=010d15622819c, content=<a href='/topic/show?id=f69d864413' target=_blank style='color:#2F92EE;'>#HEART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8644, encryptionId=f69d864413, topicName=HEART)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=)]
    2015-01-22 Jiangyh0406

    AKI的诊断依据?很好的分析和诠释!

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=33762, encodeId=301833e62af, content=哦, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3ykRSkuxjt93yc9tvDWfIQItrwiaKSCps5kyrTyDlwic2FgoCWe88wR3ZiaggKYGueDIp26zVgnbzriaQ/0, createdBy=89d71602869, createdName=sundong, createdTime=Wed Jul 29 11:19:00 CST 2015, time=2015-07-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=26900, encodeId=ecda2690012, content=需要更多的文献帮助理解这个新观点, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ed101627734, createdName=Messichen1992, createdTime=Wed Jun 10 16:08:00 CST 2015, time=2015-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20260, encodeId=9c5020260e9, content=AKI对心衰临床治疗意义重大,但依然需要研究检验其适用性, beContent=null, objectType=article, channel=null, level=null, likeNumber=129, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:25:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=20259, encodeId=2a4020259bd, content=轻度肾脏疾病对母亲和婴儿可能会增加孕期风险, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20150920/IMG55FDE671A89482379.jpg, createdBy=cef3108336, createdName=x35042875, createdTime=Sat Apr 11 22:23:00 CST 2015, time=2015-04-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=14572, encodeId=e04f145e226, content=AKI的诊断依据?很好的分析和诠释!, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=76f6105517, createdName=Jiangyh0406, createdTime=Thu Jan 22 10:53:00 CST 2015, time=2015-01-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1355954, encodeId=117e135595498, content=<a href='/topic/show?id=b0702e84b9' target=_blank style='color:#2F92EE;'>#ART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=2784, encryptionId=b0702e84b9, topicName=ART)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1396892, encodeId=60d2139689235, content=<a href='/topic/show?id=8bee565436d' target=_blank style='color:#2F92EE;'>#损伤#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56543, encryptionId=8bee565436d, topicName=损伤)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4dfa37, createdName=智者为医08, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1562281, encodeId=010d15622819c, content=<a href='/topic/show?id=f69d864413' target=_blank style='color:#2F92EE;'>#HEART#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=30, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8644, encryptionId=f69d864413, topicName=HEART)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Jan 18 00:15:00 CST 2015, time=2015-01-18, status=1, ipAttribution=)]
    2015-01-18 仁医06
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