Letters to the Editor – Brief Case Reports
Emphysematous pyelonephritis in a renal transplant recipient. A case study
Pielonefritis enfisematosa en trasplantado renal. Reporte de un caso
Hermann Hernández-Vargas
, Milagros Sierra-Carpio, Fernando Gil-Catalinas, Altagracia Bello-Ovalle, Inés Beired-Val, Gabriela Inés Pimentel-Guzmán, Antonio Gil-Paraíso, Marta Artamendi-Larrañaga, Cecilia Dall-Anesse, Emma Huarte-Loza
Corresponding author
Servicio de Nefrología, Hospital San Pedro, Logroño, La Rioja, Spain
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A case study" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "184" "paginaFinal" => "186" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Hermann Hernández-Vargas, Milagros Sierra-Carpio, Fernando Gil-Catalinas, Altagracia Bello-Ovalle, Inés Beired-Val, Gabriela Inés Pimentel-Guzmán, Antonio Gil-Paraíso, Marta Artamendi-Larrañaga, Cecilia Dall-Anesse, Emma Huarte-Loza" "autores" => array:10 [ 0 => array:4 [ "nombre" => "Hermann" "apellidos" => "Hernández-Vargas" "email" => array:1 [ 0 => "hermancho@msn.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Milagros" "apellidos" => "Sierra-Carpio" ] 2 => array:2 [ "nombre" => "Fernando" "apellidos" => "Gil-Catalinas" ] 3 => array:2 [ "nombre" => "Altagracia" "apellidos" => "Bello-Ovalle" ] 4 => array:2 [ "nombre" => "Inés" "apellidos" => "Beired-Val" ] 5 => array:2 [ "nombre" => "Gabriela Inés" "apellidos" => "Pimentel-Guzmán" ] 6 => array:2 [ "nombre" => "Antonio" "apellidos" => "Gil-Paraíso" ] 7 => array:2 [ "nombre" => "Marta" "apellidos" => "Artamendi-Larrañaga" ] 8 => array:2 [ "nombre" => "Cecilia" "apellidos" => "Dall-Anesse" ] 9 => array:2 [ "nombre" => "Emma" "apellidos" => "Huarte-Loza" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Hospital San Pedro, Logroño, La Rioja, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pielonefritis enfisematosa en trasplantado renal. Reporte de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 544 "Ancho" => 1459 "Tamanyo" => 93773 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal CAT scan.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Emphysematous pyelonephritis (EPN) is a rare necrotizing condition of the kidney, and is particularly rare in renal transplant recipients. It is characterized by the presence of gas in the renal parenchyma, the perirenal space, or the urinary tract as a result of an infection. Infection is generally caused by gas-producing microorganisms, including <span class="elsevierStyleItalic">Escherichia coli</span> (over 80% of cases) or <span class="elsevierStyleItalic">Klebsiella pneumoniae</span>, due to mixed fermentation of glucose.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Over 80% of cases have been described in diabetic patients. Urinary tract obstruction is a major risk factor of EPN, and women are affected more often in a 4:1 ratio.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Mortality from EPN is primarily attributable to septic complications, with almost 78% of cases reported by the late 1970s. However, the improvement in management techniques has reduced this figure to 21% over the last two decades.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical course of EPN is typically severe and rapidly progresses to sepsis with multiple organ failures. CAT scans are considered the gold standard for diagnosis and staging.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The time between graft placement and the development of EPN among renal transplant recipients as reported in the literature ranges from two weeks to 15 years.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,5</span></a> Al-Geizawi et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> suggest a classification of EPN into renal grafts based on CAT findings. This will require prospective validation however, but it is an alternative to previous classifications of EPN in native kidneys. This classification would help guide medical or surgical treatment, depending on the indication.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a non-diabetic and non-hypertensive 50-year-old patient with a history of renal failure secondary to reflux-associated chronic pyelonephritis, and a history of four renal transplants (1992, 2001, 2006, and 2010). Vascular endoprosthesis and intraperitoneal placement were required in the last renal graft placement in the left iliac fossa (LIF). Graft loss resulted from: (1) suspected chronic nephropathy of the graft, with three episodes of acute rejection with transplantectomy in 1999; (2) early obstructive uropathy with transplantectomy one year later; (3) thrombotic microangiopathy associated with humoral rejection, and (4) suspected humoral rejection. As a consequence, haemodialysis was restarted in November 2011, immunosuppressants had been tapered and oral corticoids had been continued.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient presented at the emergency department with haemorrhagic shock resulting from rectal bleeding. There were no previous fever or symptoms. The case also had previous haemodialysis sessions with no incidents. Investigations revealed: generalized pallor, diaphoresis, afebrile, and poor performance status with haemodynamic instability (BP: 82/56<span class="elsevierStyleHsp" style=""></span>mmHg, HR: 133<span class="elsevierStyleHsp" style=""></span>bpm, and SaO<span class="elsevierStyleInf">2</span> 70%). Mild abdominal pain in the mesogaster, with no signs of peritoneal irritation was observed. Rectal examination had shown fresh blood. There was an unpainful renal graft in LIF. Emergency tests revealed severe anaemia with positive sepsis markers (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was admitted into the intensive care unit (ICU) with volemic replacement of 7 concentrates of red blood cells. No bleeding focus was observed in the colonoscopy, the abdominal CT angiography, and the aortography. Abundant gas was seen in the interior of the LIF renal graft (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), leading to the initiation of broad-spectrum antibiotics (piperacillin/tazobactam). Following ICU discharge, the patient was referred to Nephrology, and a new colonoscopy was still unable to reveal the origin of bleeding. Persistent gas was confirmed by ultrasound at the level of the renal graft.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A LIF renal graft transplantectomy showed an unstructured kidney with abscess formation. The pathology report revealed ischaemic necrosis with renal artery thrombus. <span class="elsevierStyleItalic">K. pneumoniae</span> and <span class="elsevierStyleItalic">Klebsiella oxytoca</span> were isolated from cultures.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient made good progress following the procedure. Some days later a new episode of melena occured and an arteriovenous fistula was evidenced from the distal mesenteric artery, as seen in the CT angiography. Medical nephrectomy was performed with a satisfactory outcome.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient died after two new episodes of rectal bleeding and anaemia.</p><p id="par0050" class="elsevierStylePara elsevierViewall">A case of EPN is described in a patient with a non-functioning renal graft following the analysis of an episode of digestive haemorrhage. Typical imaging consistent with this disease is described in the CAT scan of the case. Treatment included transplantectomy and wide-spectrum antibiotics. There was histological evidence of injuries consistent with EPN in the patient. Two microorganisms commonly reported to be isolated in the literature, <span class="elsevierStyleItalic">K. pneumoniae</span> and <span class="elsevierStyleItalic">K. oxytoca</span>, were found in cultures of the pathological specimen of this case.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Companion diagnostics must be made with the presence of renal abscesses, xanthogranulomatous pyelonephritis, and renal tuberculosis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Even though our patient was not diabetic, the history of immunosuppression due to multiple previous renal transplants may become a risk factor associated with EPN.</p><p id="par0065" class="elsevierStylePara elsevierViewall">This kind of clinical cases should be reported to further investigate their epidemiology and clarify the pathogenic aspects guiding the selection of optimal treatment for future cases.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6–9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Hernández-Vargas H, Sierra-Carpio M, Gil-Catalinas F, Bello-Ovalle A, Beired-Val I, Pimentel-Guzmán GI, et al. Pielonefritis enfisematosa en trasplantado renal. Reporte de un caso. Nefrologia. 2016;36:184–186.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 544 "Ancho" => 1459 "Tamanyo" => 93773 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal CAT scan.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">4<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">16<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Urea (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">150 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">208 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Creatinine (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Amylase (U/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">219 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">545 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">448 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">295 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lactate (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>RCP (mg/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">220 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">125 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Haemoglobin (g/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Haematocrits (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Platelets (per μL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">556,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">187,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">206,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">White blood cells (per μL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5600 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6600 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6400 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Procalcitonin (ng/mL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>100 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 10 | 21 |
| 2024 October | 51 | 47 | 98 |
| 2024 September | 63 | 37 | 100 |
| 2024 August | 89 | 81 | 170 |
| 2024 July | 52 | 30 | 82 |
| 2024 June | 78 | 40 | 118 |
| 2024 May | 65 | 43 | 108 |
| 2024 April | 52 | 38 | 90 |
| 2024 March | 62 | 25 | 87 |
| 2024 February | 55 | 31 | 86 |
| 2024 January | 50 | 21 | 71 |
| 2023 December | 60 | 23 | 83 |
| 2023 November | 49 | 28 | 77 |
| 2023 October | 83 | 30 | 113 |
| 2023 September | 91 | 33 | 124 |
| 2023 August | 52 | 27 | 79 |
| 2023 July | 46 | 32 | 78 |
| 2023 June | 33 | 18 | 51 |
| 2023 May | 50 | 37 | 87 |
| 2023 April | 41 | 11 | 52 |
| 2023 March | 54 | 19 | 73 |
| 2023 February | 38 | 25 | 63 |
| 2023 January | 30 | 23 | 53 |
| 2022 December | 51 | 28 | 79 |
| 2022 November | 58 | 31 | 89 |
| 2022 October | 53 | 42 | 95 |
| 2022 September | 53 | 36 | 89 |
| 2022 August | 45 | 62 | 107 |
| 2022 July | 34 | 38 | 72 |
| 2022 June | 34 | 28 | 62 |
| 2022 May | 60 | 38 | 98 |
| 2022 April | 69 | 55 | 124 |
| 2022 March | 50 | 55 | 105 |
| 2022 February | 62 | 41 | 103 |
| 2022 January | 77 | 34 | 111 |
| 2021 December | 88 | 45 | 133 |
| 2021 November | 56 | 42 | 98 |
| 2021 October | 51 | 49 | 100 |
| 2021 September | 44 | 44 | 88 |
| 2021 August | 38 | 35 | 73 |
| 2021 July | 52 | 45 | 97 |
| 2021 June | 25 | 28 | 53 |
| 2021 May | 41 | 36 | 77 |
| 2021 April | 68 | 67 | 135 |
| 2021 March | 91 | 32 | 123 |
| 2021 February | 76 | 26 | 102 |
| 2021 January | 52 | 20 | 72 |
| 2020 December | 47 | 11 | 58 |
| 2020 November | 40 | 20 | 60 |
| 2020 October | 35 | 17 | 52 |
| 2020 September | 38 | 16 | 54 |
| 2020 August | 38 | 13 | 51 |
| 2020 July | 55 | 12 | 67 |
| 2020 June | 35 | 13 | 48 |
| 2020 May | 50 | 13 | 63 |
| 2020 April | 42 | 19 | 61 |
| 2020 March | 43 | 14 | 57 |
| 2020 February | 39 | 20 | 59 |
| 2020 January | 42 | 23 | 65 |
| 2019 December | 54 | 29 | 83 |
| 2019 November | 44 | 22 | 66 |
| 2019 October | 40 | 28 | 68 |
| 2019 September | 34 | 17 | 51 |
| 2019 August | 34 | 19 | 53 |
| 2019 July | 37 | 32 | 69 |
| 2019 June | 35 | 19 | 54 |
| 2019 May | 35 | 21 | 56 |
| 2019 April | 72 | 35 | 107 |
| 2019 March | 43 | 32 | 75 |
| 2019 February | 28 | 20 | 48 |
| 2019 January | 44 | 27 | 71 |
| 2018 December | 144 | 48 | 192 |
| 2018 November | 256 | 16 | 272 |
| 2018 October | 191 | 16 | 207 |
| 2018 September | 104 | 13 | 117 |
| 2018 August | 61 | 22 | 83 |
| 2018 July | 63 | 16 | 79 |
| 2018 June | 53 | 12 | 65 |
| 2018 May | 78 | 19 | 97 |
| 2018 April | 95 | 8 | 103 |
| 2018 March | 85 | 10 | 95 |
| 2018 February | 144 | 8 | 152 |
| 2018 January | 60 | 6 | 66 |
| 2017 December | 137 | 5 | 142 |
| 2017 November | 65 | 15 | 80 |
| 2017 October | 42 | 6 | 48 |
| 2017 September | 50 | 13 | 63 |
| 2017 August | 25 | 6 | 31 |
| 2017 July | 39 | 9 | 48 |
| 2017 June | 49 | 9 | 58 |
| 2017 May | 42 | 6 | 48 |
| 2017 April | 51 | 13 | 64 |
| 2017 March | 26 | 11 | 37 |
| 2017 February | 28 | 6 | 34 |
| 2017 January | 21 | 10 | 31 |
| 2016 December | 52 | 11 | 63 |
| 2016 November | 69 | 17 | 86 |
| 2016 October | 77 | 20 | 97 |
| 2016 September | 101 | 5 | 106 |
| 2016 August | 132 | 3 | 135 |
| 2016 July | 140 | 7 | 147 |
| 2016 June | 121 | 0 | 121 |
| 2016 May | 145 | 0 | 145 |
| 2016 April | 118 | 0 | 118 |
| 2016 March | 70 | 0 | 70 |
| 2016 February | 83 | 0 | 83 |
| 2016 January | 70 | 0 | 70 |
| 2015 December | 63 | 0 | 63 |
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