Review
Choice of fluids in the perioperative period of kidney transplantation
Elección de fluidos en el periodo perioperatorio del trasplante renal
Alejandro Gonzalez-Castro
, María Ortiz-Lasa, Yhivian Peñasco, Camilo González, Carmen Blanco, Juan Carlos Rodriguez-Borregan
Corresponding author
Unidad Polivalente, Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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To achieve this goal, an adequate understanding and management of fluid therapy is essential; a major surgery is commonly associated to renal insufficiency and electrolytic disorders such as hyperkalemia that should be prevented and the function of the graft needs to be warranted.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Delayed graft function is a term used to describe acute renal failure after transplantation and may be defined by the need for dialysis during the first postoperative week. Delayed graft function is important predictor of the subsequent clinical course of the graft.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1,2</span></a> There are several factors that are related to a delayed graft function: age of donor, quality of the tissues, cold storage, reperfusion injury, prerenal causes, immunosuppressive drugs, etc.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">3,4</span></a> Likewise, the presence of hyperkalemia may contribute to graft dysfunction.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">5</span></a> Classically, normal saline (NS) has been chosen during the perioperative period of renal transplantation. This choice has been based on the belief that the use of potassium containing replacement fluids could produce hyperkalemia.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">However, there are views that attribute to NS an increase of serum chlorine that predispose to the development of metabolic acidosis and the generation of hyperkalemia through a transcellular movement of ions. This concept has been that basis for the elaboration of several studies during the last decade comparing the use of NS and balanced crystalloid solutions (including potassium in their formulation) during the perioperative period of renal transplantation.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">7–11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The present short reviews is brief pathophysiological assessment of this concept as well as a description of the publications in the current medical literature.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Type of fluids</span><p id="par0025" class="elsevierStylePara elsevierViewall">Intravenous fluids are separated into 2 types: crystalloids and colloids. Crystalloids are made of sterile water and electrolytes and sometimes contain glucose as a source of calories. Colloids are solutions containing high molecular weight particles that increase oncotic pressure and are added to a crystalloid. This group includes albumin, gelatins, dextrans and starches (derived from corn and potato).<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The increase in oncotic pressure increases intravascular fluid retention capacity as compared to crystalloids. This theory is based on the theoretical premise that larger particles are trapped in the intravascular space by an intact endothelial barrier for longer period of time.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">However, it is necessary to consider that a colloid only behaves as a colloid (that is, increasing oncotic pressure) when the glycocalyx is intact.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">14</span></a> In fact, in the perioperative period (in situations such as preoperative fasting) bleeding and insensible losses can reduce the extracellular volume and activate the inflammatory cascade, with consequent damage of the glycocalyx, which increases capillary permeability and looses of intravascular fluids.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">15,16</span></a> This fact explains why large clinical trials observed that the advantage in volume expansion is generally only about 30–40% in favor of colloids, far from theoretical potency in situations of intact glycocalyx.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">17–19</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Furthermore, the use of colloids increases the cost, have limited availability (the case of albumin, which is a blood product) and are associated with clotting disorders that may cause persistent renal damage, mainly observed with the use of hydroxy-ethyl starches.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">20–23</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">These details may have led clinicians to choose crystalloids as the first option in the postoperative period of renal transplantation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Crystalloids are classified into 2 large groups. Unbalanced and balanced crystalloids; the NS is considered unbalanced fluid.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The NS contains 154<span class="elsevierStyleHsp" style=""></span>mEq/L of sodium and 154<span class="elsevierStyleHsp" style=""></span>mEq/L of chloride; therefore it has no buffer capacity.</p><p id="par0060" class="elsevierStylePara elsevierViewall">From the standpoint of renal hemodynamics, it tends to reduce the volume of diuresis, prolonging it over time. The activity of natriuretic factors, the inhibition of antinatriuretic system and the effect on cardiac output is similar to that of balanced solutions,<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a> but the water management is different from unbalanced crystalloid solution. With very large volumes of infusion and in the absence of spurious stimuli of ADH, it tends to produce hypernatremia. By contrast, the infusion of discreetly hypotonic solutions in large quantities favors hyponatremia more than hypernatremia.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">25,26</span></a> The relative hypotonicity of certain balanced crystalloids solutions causes inhibition of ADH and the water diuresis occurs earlier and more satisfactory than with NS.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">26</span></a> However, at this point it is important to remember that the inhibition of ADH release induced by resuscitation together with administration of hypoosmotic balanced solutions will promote the entry of water into the interstitial space, with the consequent deleterious effect that may occur in certain clinical circumstances.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">27</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">With regard to glomerular filtration, the infusion of NS, by distending the right cardiac cavities, increases the secretion of atrial natriuretic peptide, which dilates the afferent artery and inhibits the sodium channels of the collecting tubule. Therefore, the delay in the initiation of diuresis is a tubular effect, secondary to the activation of ADH due to a relative hypertonicity, so it requires a considerable volume of infusion.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Hypovolemia due to situations as surgical interventions, forced diuresis, development of a third space or drainage, produce activation of the renin-angiotensin-aldosterone axis and increase in thirst.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a> It should be remembered that the patient will develop hyponatremia if they are allowed to drink without salt, if we resuscitate with hypotonic solutions or glucose containing fluids without salt. Such salt depletion may increase the dependence of glomerular filtration on an intact renin-angiotensin system and sensitize the patient to the development of acute renal failure.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Hyperchloremia, hyperchloremic metabolic acidosis and hyperkalemia</span><p id="par0075" class="elsevierStylePara elsevierViewall">According to the Stewart model, the physical–chemical approach to the analysis of acid-base balance confers a predominant role to chloride, and hyperchloremia.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">31</span></a> The administration of fluids with supraphysiological concentrations of chloride and abnormal sodium-chloride concentration (NS) with respect to plasma will contribute to the development of hyperchloremic metabolic acidosis, since the relative increases in the concentration of chloride will cause a decrease in the difference of strong ions.<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">32</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Apart from the clinical effects of acidosis (reduction of cardiac contractility, reduction of catecholamine effects, alterations in coagulation or platelet function<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">33</span></a>), it is necessary to recall its effect on the regulation of serum potassium.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Approximately 98% of potassium is present within cells, with an intracellular concentration of ∼140<span class="elsevierStyleHsp" style=""></span>mEq/L. Therefore, small changes in intracellular potassium will have a significant effect on extracellular potassium levels. In this context, hyperchloremic metabolic acidosis will cause the H+ ion to enter the cell to be neutralized with the intracellular buffer, with subsequent shifting of potassium outside the cells, which will increase the concentration of extracellular potassium<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">34,35</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Presumably, in a standard individual receiving a saline crystalloid con150<span class="elsevierStyleHsp" style=""></span>mEq/L of chloride in its formulation, the serum potassium would increase above 5<span class="elsevierStyleHsp" style=""></span>mEq/L for a volume infusion greater than 4<span class="elsevierStyleHsp" style=""></span>L (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In the case of infusion of balanced solutions with buffer capacity, the presence of lactate or acetate will result in equivalent amounts of bicarbonate, which will prevent or minimize hyperchloremic acidosis. In fact, if such buffered solutions did not contain potassium in their formulation, the dilution effect on serum potassium concentration would cause hypokalemia by dilution.</p><p id="par0095" class="elsevierStylePara elsevierViewall">At this point, it is important to note that the theoretical pathophysiological models support that the metabolism of lactate and acetate to achieve the production of bicarbonate differ in several aspects. First, it is considered that the production of bicarbonate from acetate is faster, with less oxygen consumption and not dependent exclusively on hepatic metabolism. Second, it does not interfere with gluconeogenesis and it is not a marker of tissue hypoxia, unlike lactate.<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">36,37</span></a> In this sense, an observational study carried out on burn patients, comparing both buffer solutions, showed that in the first 5 days the serum lactate concentrations were significantly lower in the acetate group, with values of excess of bases significantly lower, although within the normal limits. The authors hypothesized that these high values of lactate with a normalization of excess bases were interpreted as being produced by the composition of the solution infused: they considered that these values of “iatrogenic” lactate was the cause of a greater infusion of fluids if there were not properly interpreted.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">36</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Presence of calcium in resuscitation solutions</span><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of calcium in the fluids may be responsible for significant clinical differences.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The effect of saline versus a calcium-balanced crystalloid was compared in an animal model subjected to uncontrolled bleeding produced by similar vascular lesions and with a therapeutic objective of maintaining a stable blood pressure. It was observed that the therapeutic goal was achieved with less volume infusion of the balanced crystalloid. Bleeding animals receiving saline have more blood losses than those treated with calcium. It is evident that the presence calcium modified the hemostasis of the animals. And, reasonably, the volume of diuresis was related to the volumes infused as the blood pressure remained constant.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">38</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">However, other authors have criticized this presence of calcium in some balanced crystalloids, arguing that they can facilitate microthrombi if they are used in large quantities in patients receiving multiple transfusions, since calcium antagonizes the effect of citrate.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">39</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The choice of fluids in the perioperative renal transplant in clinical practice</span><p id="par0115" class="elsevierStylePara elsevierViewall">The perioperative period in renal transplantation has traditionally been a period of time in which large amounts of resuscitation fluids are administered, with the ultimate aim of ensuring the function of the graft after renal transplantation.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">1,8,10</span></a> The selection of patients who required a limited amounts fluid for resuscitation has been one of the criticisms of large studies, which sought to find differences in the renal protection exerted by the balanced solutions against NS.<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">40,41</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In the last decade, several studies have compared changes the ionic and acid–base produced by different crystalloids administration during the perioperative period of renal transplantation. After searching the databases Medline, Embase, Cochrane Database and Lilacs, we describe, according to year of publication, the most relevant studies in this regard:</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">O’Malley CM et al., year 2005: A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation</span>.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">7</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Study carried out in 51 patients including live donors or cadaveric transplants. Exclusion criteria were serum potassium levels >5.5<span class="elsevierStyleHsp" style=""></span>mEq/L pre-surgery. Twenty-five patients were randomized to the balanced crystalloid group and 26 to the NS group. The primary endpoint of the study was to determine differences in serum creatinine on the third postoperative day.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The mean creatinine value (mg/dL) on day 3 was 2.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.8 in the balanced crystalloid group versus 2.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.7 in the NS group (with no statistical significance). Five patients (19%) in the NS group versus zero patients (0%) in the balancing group had potassium concentrations ≥6<span class="elsevierStyleHsp" style=""></span>mEq/L and the hyperkalemia had to be treated (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.05). Eight patients (31%) in the NS group versus zero patients (0%) in the balanced crystalloid group were treated for metabolic acidosis (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004).</p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hadimioglu et al., year 2008: The effect of different crystalloid solutions on acid–base balance and early kidney function after kidney transplantation.</span><a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">10</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In this double-blind study, patients were randomly assigned to 3 groups (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>30) to receive NS, lactated Ringer's (RL), or Plasmalyte at doses of 20–30<span class="elsevierStyleHsp" style=""></span>mL/kg. All 90 patients received live donor organ. Exclusion criteria was serum potassium levels >5.5<span class="elsevierStyleHsp" style=""></span>mEq/L pre-surgery. The primary objectives of the study were to analyze: total daily urinary volume, serum creatinine on the third postoperative day, pH, bicarbonate and potassium levels during surgery and in the postoperative period, as well as creatinine, BUN, chloride, urinary output and creatinine clearance on days 1, 2, 3 and 7.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Results showed a statistically significant reduction in pH, in excess of alkali and a significant increase in serum chloride levels in patients receiving NS during surgery. Potassium levels did not show significant changes in any group. Measured in mM/L, the chloremia ranged between 21.2 of NS, 3.3 for RL and 1.7 in Plasmalyte.</p><p id="par0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Khajavi et al., year 2008: Effects of normal saline vs. Lactated Ringer's during renal transplantation.</span><a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">8</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Randomized, double-blind study conducted in 52 patients with live donor grafts. Patients with serum potassium values ≥6<span class="elsevierStyleHsp" style=""></span>mEq/L pre-surgery were excluded. The primary objectives were to find differences in serum potassium and pH at the end of surgery. The infusion fluids were administered at 60<span class="elsevierStyleHsp" style=""></span>mL/kg according to protocol to maintain central venous pressure between 10 and 15<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The authors found hyperkalemia and acidosis more frequently in the NS group, showing a significant difference in serum potassium levels (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.000) and in pH (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.007).</p><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Modi et al., year 2012: A comparative study of impact of infusion of Ringer's lactate solution versus normal saline on acid-base balance and serum electrolytes during live related renal transplantation.</span><a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">9</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Randomized study, carried out in 74 patients (37 patients per arm) receiving infusion of RL solution versus NS; exclusion criteria was a serum potassium level ≥5.5<span class="elsevierStyleHsp" style=""></span>mEq/L pre-surgery. The primary objectives were to compare urinary output intraoperatively and during the first postoperative day, serum creatinine values on the first postoperative day, changes in pH, bicarbonate, potassium and chloride during surgery and in the postoperative period. The anesthesia protocol was to maintain the central venous pressure between 12 and 15<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0180" class="elsevierStylePara elsevierViewall">The volume administered in both groups during surgery was similar (RL<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.25<span class="elsevierStyleHsp" style=""></span>L; NS<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.1<span class="elsevierStyleHsp" style=""></span>L). The pH decreased from 7.43 to 7.33 in patients receiving NS and no pH changes were observed in the RL group. The mean value of serum creatinine on the first day after surgery was 2.43<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.87<span class="elsevierStyleHsp" style=""></span>mg/dL in the RL group and 2.82<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.75<span class="elsevierStyleHsp" style=""></span>mg/dL in the NS group. The serum potassium reached 3.99<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.71 versus 4.31<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.05 in the NS group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05). The serum chloride level was 98.50<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.03 versus 103.92<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.28 in the NS group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.05).</p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Kim et al., year 2013: Comparison of the effects of normal saline versus Plasmalyte on acid–base balance during living donor kidney transplantation using the Stewart and base excess methods.</span><a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">42</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">A double-blind study in which patients were randomized, on the day before surgery, to NS group (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>30) or to Plasmalyte (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>30). In 100% of the cases there were living donors. The fluids were administered to maintain central venous pressure between 12 and 15<span class="elsevierStyleHsp" style=""></span>mmHg. A total of 750<span class="elsevierStyleHsp" style=""></span>mL of 5% albumin was given to all patients during surgery.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Arterial blood samples were collected after induction of anesthesia (T0), immediately before the anastomosis of the iliac vein (T1), 10<span class="elsevierStyleHsp" style=""></span>min after reperfusion (T2) and at the end of surgery (T3) to measure pH, PaCO<span class="elsevierStyleInf">2</span>, excess bases, bicarbonate, sodium, potassium, chloride, lactate, phosphate and albumin. The water balance was calculated during the study, as well as serum levels of chloride and creatinine at 24<span class="elsevierStyleHsp" style=""></span>h and at days 1, 2 and 7. The acid-base state was analyzed using the physicochemical model of Stewart.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Chloride concentrations were significantly higher in T1, T2 and T3 in NS as compared to the Plamalyte group. None of the groups showed significant changes in serum K+ levels during surgery.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Postoperative serum chloride levels were not different between the 2 groups. Serum creatinine and 24-h urine volume were similar between groups.</p><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Potura et al., year 2015: An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial</span>.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">11</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">A prospective, randomized, controlled trial including 150 patients, 74 received NS and 76 a crystalloid solution balanced with acetate during and after renal cadaver transplantation. Study fluids were administered at a rate of 4<span class="elsevierStyleHsp" style=""></span>mL/kg/h (according to ideal body weight) during surgery, and at 2<span class="elsevierStyleHsp" style=""></span>mL/kg/h after surgery and during the postoperative follow up period. Exclusion criteria were potassium levels >5.5<span class="elsevierStyleHsp" style=""></span>mEq/L pre-surgery.</p><p id="par0220" class="elsevierStylePara elsevierViewall">The incidence of hyperkalemia differed between 17% and 21% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.56) and the mean serum potassium variation since the initiation of surgery to the end of the study period was similar (mEq/L) (0.8 [0.0–1.0] versus 0.6 [0.0–1.0]; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.44).</p><p id="par0225" class="elsevierStylePara elsevierViewall">Maximum serum chloride levels were significantly higher in the NS group (109<span class="elsevierStyleHsp" style=""></span>mmol/L [107–111] versus 107<span class="elsevierStyleHsp" style=""></span>mmol/L [105–109]). There was a significant trend toward developing hyperchloremia in the NS group as compared to the balanced crystalloid group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.02).</p><p id="par0230" class="elsevierStylePara elsevierViewall">More patients in the saline group, compared to the balancing group, required the administration of catecholamines for circulatory support. The difference was statistically significant.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Recently, the results of a meta-analysis with 4 of the previously described articles have been published. SELECTION CRITERIA: Randomized controlled trials were included in adult renal transplant patients who compared the safety of RL versus NS.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a> The results in relation to the development of hyperkalemia and hyperchloremia are shown in <a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">First, despite the results of the studies described above, it should be emphasized that number of studies presently available is not sufficient to make a entirely correct choice of fluids in the perioperative period of renal transplantation. In addition, the studies described so far include a low number of patients, with different periods of observation and post-transplant follow-up and the variables evaluated are not always the same; these are premises that limit the interpretation of the data.</p><p id="par0245" class="elsevierStylePara elsevierViewall">However, it can be concluded that the use of balanced crystalloids that include potassium in their formulation, during the perioperative period of renal transplantation, appear to be safe with respect to the control of serum potassium concentration. In addition, with the use balanced solutions there seems to be a better control of acid-base balance. No significant changes in serum creatinine have been observed during the perioperative period, neither at 3 nor at 7 days.<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0275" class="elsevierStylePara elsevierViewall">The corresponding author, Dr. González-Castro, declares as potential conflict of interest collaborative work with the pharmaceutical company Baxter.</p><p id="par0280" class="elsevierStylePara elsevierViewall">The rest of the authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres950342" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec922193" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres950341" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec922192" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Type of fluids" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Hyperchloremia, hyperchloremic metabolic acidosis and hyperkalemia" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Presence of calcium in resuscitation solutions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "The choice of fluids in the perioperative renal transplant in clinical practice" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-15" "fechaAceptado" => "2017-03-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec922193" "palabras" => array:5 [ 0 => "Kidney transplantation" 1 => "Normal saline" 2 => "Balanced solutions" 3 => "Hyperchloraemia" 4 => "Hyperkalaemia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec922192" "palabras" => array:5 [ 0 => "Trasplante renal" 1 => "Suero salino normal" 2 => "Soluciones balanceadas" 3 => "Hipercloremia" 4 => "Hiperpotasemia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Normal saline has traditionally been the resuscitation fluid of choice in the perioperative period of kidney transplantation over balanced potassium solutions. However, the problems arising from hyperchloraemia triggered by the infusion of normal saline have led to studies being conducted that compare this solution with balanced solutions. From this narrative review it can be concluded that the use of balanced crystalloids containing potassium in the perioperative period of kidney transplantation can be considered safe. These solutions do not affect serum potassium levels any more than normal saline, whilst maintaining a better acid–base balance in these patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El suero salino normal (SSN) ha sido clásicamente el fluido de resucitación elegido en el periodo perioperatorio del trasplante renal frente a aquellas soluciones balanceadas con potasio. Sin embargo, los problemas derivados de la hipercloremia desencadenada por la infusión de SSN han llevado a la realización de estudios que comparaban esta solución con los fluidos equilibrados. Mediante la presente revisión narrativa se deduce que el uso de cristaloides balanceados con contenido de potasio en su formulación, en el perioperatorio de trasplante renal, puede considerarse seguro. Estas soluciones no provocan una alteración del potasio sérico mayor que la provocada por el SSN y mantienen mejor el equilibrio ácido-base en estos enfermos.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gonzalez-Castro A, Ortiz-Lasa M, Peñasco Y, González C, Blanco C, Rodriguez-Borregan JC. Elección de fluidos en el periodo perioperatorio del trasplante renal. Nefrologia. 2017;37:572–578.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1151 "Ancho" => 1167 "Tamanyo" => 83343 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Effect of hyperchloremic acidosis on serum potassium concentration. <span class="elsevierStyleItalic">Source</span>: Modified from Santi et al.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">35</span></a> Transcellular shift of potassium driven by the entry of H+ into the cell where it is neutralized by intracellular buffers.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 704 "Ancho" => 3450 "Tamanyo" => 210538 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Results of the comparative meta-analysis of the Ringer's solution and the SSN, in relation to the development of hyperkalemia. <span class="elsevierStyleItalic">Source</span>: Taken from Trujillo-Zea et al.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a></p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 554 "Ancho" => 3450 "Tamanyo" => 189721 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Results of the comparative meta-analysis of the Ringer's solution and the NS, in relation to the development of hyperchloremia. <span class="elsevierStyleItalic">Source</span>: Taken from Trujillo-Zea et al.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a></p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">It is assumed 12<span class="elsevierStyleHsp" style=""></span>L of extracellular volume for a 70<span class="elsevierStyleHsp" style=""></span>kg subject. With a starting serum chloride level of 110<span class="elsevierStyleHsp" style=""></span>mEq/L and potassium of 4<span class="elsevierStyleHsp" style=""></span>mEq/L. It is infused a hypothetical saline crystalloid with a chloride concentration of 150<span class="elsevierStyleHsp" style=""></span>mEq/L.</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infused volume \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">[Cl<span class="elsevierStyleSup">−</span>] final \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">ΔCl<span class="elsevierStyleSup">−</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">ΔHCO<span class="elsevierStyleInf">3</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">[HCO<span class="elsevierStyleInf">3</span>] final \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">pCO<span class="elsevierStyleInf">2</span> expected \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">pH final \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">ΔpH \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">ΔK<span class="elsevierStyleSup">+</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">[K<span class="elsevierStyleSup">+</span>] diluted \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">[K<span class="elsevierStyleSup">+</span>] final \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">113.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.19 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">118.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">121.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1609146.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Simulation of the expected changes in the serum levels of chloride, bicarbonate, pCO<span class="elsevierStyleInf">2</span>, pH and potassium of a standard subject treated with progressive volume expansion.</p>" ] ] 4 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0250" class="elsevierStylePara elsevierViewall">Key concepts<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">The use of balanced crystalloids containing potassium in their formulation, during the perioperative period of renal transplantation, does not cause a greater alteration of serum potassium than that observed with NS.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0260" class="elsevierStylePara elsevierViewall">Hyperchloremia caused by infusion of NS causes hyperchloremic metabolic acidosis.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0265" class="elsevierStylePara elsevierViewall">Hyperchloremic metabolic acidosis may favor an increase in serum potassium concentration.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0270" class="elsevierStylePara elsevierViewall">It is necessary to perform clinical studies in these patients, in which variables of a greater clinical impact are evaluated.</p></li></ul></p></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:43 [ 0 => array:3 [ "identificador" => "bib0225" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative fluid management in renal transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 7 | 25 |
| 2024 October | 85 | 82 | 167 |
| 2024 September | 127 | 60 | 187 |
| 2024 August | 134 | 102 | 236 |
| 2024 July | 204 | 54 | 258 |
| 2024 June | 115 | 49 | 164 |
| 2024 May | 137 | 41 | 178 |
| 2024 April | 105 | 43 | 148 |
| 2024 March | 56 | 32 | 88 |
| 2024 February | 77 | 53 | 130 |
| 2024 January | 64 | 27 | 91 |
| 2023 December | 64 | 48 | 112 |
| 2023 November | 86 | 43 | 129 |
| 2023 October | 114 | 40 | 154 |
| 2023 September | 134 | 39 | 173 |
| 2023 August | 158 | 41 | 199 |
| 2023 July | 115 | 35 | 150 |
| 2023 June | 106 | 24 | 130 |
| 2023 May | 126 | 39 | 165 |
| 2023 April | 94 | 32 | 126 |
| 2023 March | 108 | 26 | 134 |
| 2023 February | 120 | 31 | 151 |
| 2023 January | 106 | 47 | 153 |
| 2022 December | 127 | 41 | 168 |
| 2022 November | 98 | 41 | 139 |
| 2022 October | 129 | 60 | 189 |
| 2022 September | 134 | 43 | 177 |
| 2022 August | 127 | 57 | 184 |
| 2022 July | 172 | 65 | 237 |
| 2022 June | 121 | 70 | 191 |
| 2022 May | 130 | 60 | 190 |
| 2022 April | 123 | 76 | 199 |
| 2022 March | 166 | 61 | 227 |
| 2022 February | 129 | 74 | 203 |
| 2022 January | 188 | 59 | 247 |
| 2021 December | 151 | 73 | 224 |
| 2021 November | 162 | 72 | 234 |
| 2021 October | 183 | 71 | 254 |
| 2021 September | 138 | 59 | 197 |
| 2021 August | 196 | 72 | 268 |
| 2021 July | 140 | 57 | 197 |
| 2021 June | 129 | 49 | 178 |
| 2021 May | 129 | 64 | 193 |
| 2021 April | 335 | 113 | 448 |
| 2021 March | 279 | 74 | 353 |
| 2021 February | 162 | 52 | 214 |
| 2021 January | 91 | 25 | 116 |
| 2020 December | 86 | 49 | 135 |
| 2020 November | 116 | 27 | 143 |
| 2020 October | 100 | 46 | 146 |
| 2020 September | 121 | 45 | 166 |
| 2020 August | 99 | 26 | 125 |
| 2020 July | 160 | 39 | 199 |
| 2020 June | 134 | 31 | 165 |
| 2020 May | 148 | 38 | 186 |
| 2020 April | 116 | 35 | 151 |
| 2020 March | 174 | 42 | 216 |
| 2020 February | 134 | 41 | 175 |
| 2020 January | 196 | 49 | 245 |
| 2019 December | 195 | 55 | 250 |
| 2019 November | 197 | 62 | 259 |
| 2019 October | 198 | 61 | 259 |
| 2019 September | 294 | 42 | 336 |
| 2019 August | 180 | 79 | 259 |
| 2019 July | 174 | 56 | 230 |
| 2019 June | 135 | 47 | 182 |
| 2019 May | 140 | 72 | 212 |
| 2019 April | 212 | 86 | 298 |
| 2019 March | 137 | 58 | 195 |
| 2019 February | 73 | 49 | 122 |
| 2019 January | 85 | 42 | 127 |
| 2018 December | 159 | 55 | 214 |
| 2018 November | 376 | 37 | 413 |
| 2018 October | 175 | 28 | 203 |
| 2018 September | 138 | 43 | 181 |
| 2018 August | 76 | 22 | 98 |
| 2018 July | 82 | 20 | 102 |
| 2018 June | 68 | 14 | 82 |
| 2018 May | 124 | 21 | 145 |
| 2018 April | 65 | 11 | 76 |
| 2018 March | 173 | 17 | 190 |
| 2018 February | 47 | 7 | 54 |
| 2018 January | 52 | 9 | 61 |
| 2017 December | 52 | 16 | 68 |
| 2017 November | 13 | 1 | 14 |
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