Letter to the Editor
Treatment of the testosterone deficiency in hemodialysis patients. Preliminary results
Tratamiento de la deficiencia androgénica del enfermo dializado con suplementos de testosterona. Resultados preliminares
Saul Pampa Saicoa,c, José Luis Teruel Brionesa,c,
, Milagros Fernández Lucasa,c, María Delgado Yagüea,c, Ana M. García Canob,c, Fernando Liaño Garcíaa,c
Corresponding author
a Servicio de Nefrología, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain
b Servicio de Bioquímica, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain
c Red de Investigación Renal (REDinREN), Madrid, Spain
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García Cano, Fernando Liaño García" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Saul" "apellidos" => "Pampa Saico" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 1 => array:4 [ "nombre" => "José Luis" "apellidos" => "Teruel Briones" "email" => array:1 [ 0 => "jteruel.hrc@salud.mdrid.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Milagros" "apellidos" => "Fernández Lucas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "María" "apellidos" => "Delgado Yagüe" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Ana M." "apellidos" => "García Cano" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "Fernando" "apellidos" => "Liaño García" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Bioquímica, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Red de Investigación Renal (REDinREN), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la deficiencia androgénica del enfermo dializado con suplementos de testosterona. Resultados preliminares" ] ] "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" => 838 "Ancho" => 1361 "Tamanyo" => 46611 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Treatment group: changes in total serum testosterone level, in each case.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Androgen deficiency is an endocrine abnormality that is common in male patients with chronic kidney disease and affects 50%–75% of patients treated with haemodialysis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Its clinical significance is not well known, although various cross-sectional studies have linked low testosterone levels to sexual dysfunction, anaemia, loss of muscle mass, increase in cardiovascular risk and greater mortality.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2–5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Androgens in pharmacological doses have effects on anaemia and nutritional parameters in patients treated with regular haemodialysis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> However, few studies have analysed the effect of treating hypogonadism from renal failure with physiological doses of testosterone, and their results have been controversial.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this study we present the preliminary data for the results obtained following correction of androgen deficiency in patients treated with haemodialysis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We defined androgen deficiency as a total serum testosterone concentration lower than 300<span class="elsevierStyleHsp" style=""></span>ng/dl and an unbound testosterone concentration lower than 225<span class="elsevierStyleHsp" style=""></span>pMol/l. Testosterone circulates in plasma bound to proteins (especially albumin and a transport globulin [sex hormone-binding globulin, or SHBG]); only 1%–3% circulates unbound. A uraemic patient may have an abnormal SHBG concentration.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Therefore, in patients with chronic kidney disease it is advisable to confirm testosterone deficiency by determining the concentration of unbound testosterone, especially in cases with a total testosterone level that is low but close to the lower limit of the normal range. Unbound testosterone was calculated based on levels of total testosterone, SHBG and albumin.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The study was conducted in male patients treated with regular haemodialysis for more than 6 months who were in a stable clinical situation and had not required admission in the last 3 months. All draws for laboratory testing were performed immediately before the first haemodialysis session of the week.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of the 39 patients analysed, 20 (51%) had a total testosterone concentration lower than 300<span class="elsevierStyleHsp" style=""></span>ng/dl, all had an unbound testosterone concentration lower than 225<span class="elsevierStyleHsp" style=""></span>pMol/l, and all were diagnosed with androgen deficiency. Twelve of these 20 patients agreed to participate in the study and granted their written consent. Patients were randomly assigned to the treatment group (6 patients who received testosterone by the transdermal route: one sachet of 5<span class="elsevierStyleHsp" style=""></span>g of gel containing 50<span class="elsevierStyleHsp" style=""></span>mg of testosterone daily for 3 months) or the control group (the other 6 patients). The dose of testosterone administered to the treatment group was the minimum initial dose recommended in the medicine's summary of product characteristics.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients in the treatment group had a younger age (67<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4 vs 75<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9 years; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.182), and at baseline there were no differences between the two groups in terms of the other parameters analysed. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the changes in these parameters. The unbound and total serum testosterone concentration increased in all patients treated, but it only reached the normal range in 4 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Neither of the 2 groups of patients showed a change in concentrations of total cholesterol, HDL cholesterol, LDL cholesterol or triglycerides (data not shown).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The prevalence of androgen deficiency in male patients from the haemodialysis unit was 51%. This figure was similar to that observed in other studies. Transdermal administration of testosterone, in the minimum dose recommended in the summary of product characteristics, increased the serum level of the hormone and had an inhibitory effect on the hypothalamic–pituitary axis. In 4 of the 6 patients treated, the total testosterone concentration exceeded the lower limit of the range considered to be normal, but the dose administered was not sufficient to reach the mean levels of this range (300–900<span class="elsevierStyleHsp" style=""></span>ng/ml).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The increases in testosterone concentration achieved, though small, were associated with a reduction in needs for erythropoietin alfa and a modest but significant increase in albumin concentration.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This was a preliminary study, conducted in a small number of patients during a short follow-up period, but its results suggest that androgen deficiency in patients with chronic kidney disease may be clinically significant, with repercussions for anaemia and nutrition, as some cross-sectional studies have suggested. They also suggest that replacement therapy may have beneficial effects on these complications.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pampa Saico S, Teruel Briones JL, Fernández Lucas M, Delgado Yagüe M, García Cano AM, Liaño García F. Tratamiento de la deficiencia androgénica del enfermo dializado con suplementos de testosterona. Resultados preliminares. Nefrologia. 2016;36:462–463.</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" => 838 "Ancho" => 1361 "Tamanyo" => 46611 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Treatment group: changes in total serum testosterone level, in each case.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The normal value is in square brackets and the standard deviation is in parentheses.</p>" "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"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment group</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Control group</th></tr><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">3 months \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"><span class="elsevierStyleItalic">p</span> \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">3 months \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"><span class="elsevierStyleItalic">p</span> \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">Total testosterone [300–900<span class="elsevierStyleHsp" style=""></span>ng/dl] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">188 (54) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">335 (113) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">174 (75) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">189 (77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.105 \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">Unbound testosterone [>225<span class="elsevierStyleHsp" style=""></span>pMol/l] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">147 (48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">279 (109) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.034 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102 (49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">114 (71) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.310 \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">FSH [1–12<span class="elsevierStyleHsp" style=""></span>mIU/l] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.4 (12.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.4 (10.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.035 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.1 (7.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.9 (9.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.746 \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">LH [1.1–8.8<span class="elsevierStyleHsp" style=""></span>mIU/l] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.9 (15.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.5 (10.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.026 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.6 (8.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.3 (8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.324 \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">11.4 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.2 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.562 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.6 (1.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.6 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.180 \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">EPO alfa [IU/kg/week] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">103 (82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 (76) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.044 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">124 (104) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">121 (114) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.889 \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">Albumin [g/dl] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (0.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.1 (0.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.242 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 50 | 31 | 81 |
| 2024 September | 57 | 20 | 77 |
| 2024 August | 77 | 52 | 129 |
| 2024 July | 43 | 24 | 67 |
| 2024 June | 73 | 25 | 98 |
| 2024 May | 76 | 30 | 106 |
| 2024 April | 44 | 34 | 78 |
| 2024 March | 52 | 19 | 71 |
| 2024 February | 34 | 30 | 64 |
| 2024 January | 35 | 22 | 57 |
| 2023 December | 47 | 18 | 65 |
| 2023 November | 36 | 24 | 60 |
| 2023 October | 57 | 38 | 95 |
| 2023 September | 42 | 30 | 72 |
| 2023 August | 42 | 26 | 68 |
| 2023 July | 61 | 27 | 88 |
| 2023 June | 69 | 16 | 85 |
| 2023 May | 67 | 36 | 103 |
| 2023 April | 39 | 18 | 57 |
| 2023 March | 54 | 19 | 73 |
| 2023 February | 56 | 13 | 69 |
| 2023 January | 61 | 30 | 91 |
| 2022 December | 62 | 23 | 85 |
| 2022 November | 69 | 24 | 93 |
| 2022 October | 66 | 45 | 111 |
| 2022 September | 49 | 36 | 85 |
| 2022 August | 60 | 35 | 95 |
| 2022 July | 54 | 44 | 98 |
| 2022 June | 74 | 23 | 97 |
| 2022 May | 50 | 36 | 86 |
| 2022 April | 66 | 54 | 120 |
| 2022 March | 86 | 42 | 128 |
| 2022 February | 54 | 29 | 83 |
| 2022 January | 68 | 38 | 106 |
| 2021 December | 68 | 29 | 97 |
| 2021 November | 52 | 46 | 98 |
| 2021 October | 60 | 42 | 102 |
| 2021 September | 48 | 31 | 79 |
| 2021 August | 50 | 36 | 86 |
| 2021 July | 47 | 33 | 80 |
| 2021 June | 80 | 28 | 108 |
| 2021 May | 77 | 49 | 126 |
| 2021 April | 144 | 65 | 209 |
| 2021 March | 78 | 27 | 105 |
| 2021 February | 61 | 30 | 91 |
| 2021 January | 46 | 18 | 64 |
| 2020 December | 39 | 20 | 59 |
| 2020 November | 40 | 19 | 59 |
| 2020 October | 19 | 16 | 35 |
| 2020 September | 28 | 9 | 37 |
| 2020 August | 45 | 14 | 59 |
| 2020 July | 38 | 18 | 56 |
| 2020 June | 27 | 18 | 45 |
| 2020 May | 33 | 10 | 43 |
| 2020 April | 27 | 17 | 44 |
| 2020 March | 37 | 16 | 53 |
| 2020 February | 31 | 18 | 49 |
| 2020 January | 39 | 19 | 58 |
| 2019 December | 45 | 26 | 71 |
| 2019 November | 23 | 23 | 46 |
| 2019 October | 27 | 14 | 41 |
| 2019 September | 34 | 19 | 53 |
| 2019 August | 14 | 17 | 31 |
| 2019 July | 26 | 25 | 51 |
| 2019 June | 22 | 18 | 40 |
| 2019 May | 17 | 24 | 41 |
| 2019 April | 48 | 34 | 82 |
| 2019 March | 39 | 24 | 63 |
| 2019 February | 26 | 15 | 41 |
| 2019 January | 28 | 19 | 47 |
| 2018 December | 139 | 51 | 190 |
| 2018 November | 242 | 19 | 261 |
| 2018 October | 204 | 21 | 225 |
| 2018 September | 121 | 17 | 138 |
| 2018 August | 67 | 18 | 85 |
| 2018 July | 58 | 11 | 69 |
| 2018 June | 67 | 10 | 77 |
| 2018 May | 95 | 15 | 110 |
| 2018 April | 169 | 8 | 177 |
| 2018 March | 98 | 8 | 106 |
| 2018 February | 80 | 3 | 83 |
| 2018 January | 57 | 5 | 62 |
| 2017 December | 107 | 10 | 117 |
| 2017 November | 62 | 14 | 76 |
| 2017 October | 30 | 3 | 33 |
| 2017 September | 57 | 14 | 71 |
| 2017 August | 61 | 4 | 65 |
| 2017 July | 67 | 8 | 75 |
| 2017 June | 54 | 14 | 68 |
| 2017 May | 53 | 11 | 64 |
| 2017 April | 63 | 8 | 71 |
| 2017 March | 42 | 5 | 47 |
| 2017 February | 37 | 7 | 44 |
| 2017 January | 25 | 12 | 37 |
| 2016 December | 45 | 8 | 53 |
| 2016 November | 48 | 16 | 64 |
| 2016 October | 62 | 7 | 69 |
| 2016 September | 119 | 2 | 121 |
| 2016 August | 119 | 2 | 121 |
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