Light chain deposition disease. Experience in our environment
Enfermedad por depósito de cadenas ligeras. Experiencia en nuestro medio.
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Complicaciones en su inserción." ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pilar Royo, Alicia García-Testal, Amparo Soldevila, Joaquín Panadero, Jose Miguel Cruz" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Pilar" "apellidos" => "Royo" ] 1 => array:2 [ "nombre" => "Alicia" "apellidos" => "García-Testal" ] 2 => array:2 [ "nombre" => "Amparo" "apellidos" => "Soldevila" ] 3 => array:2 [ "nombre" => "Joaquín" "apellidos" => "Panadero" ] 4 => array:2 [ "nombre" => "Jose Miguel" "apellidos" => "Cruz" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699508003998" "doi" => " " "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508003998?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408003995?idApp=UINPBA000064" "url" => "/20132514/0000002800000005/v0_201502091635/X2013251408003995/v0_201502091635/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "X2013251408003936" "issn" => "20132514" "doi" => " " "estado" => "S300" "fechaPublicacion" => "2008-10-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2008;28:531-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4546 "formatos" => array:3 [ "EPUB" => 284 "HTML" => 3520 "PDF" => 742 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Changes in vascular access in a dialysis unit in recent years: planning problems, change in preferences, or demographic change?" 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Experience in our environment" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "539" "paginaFinal" => "542" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Carmen Martin Herrera, Marta Suñer Poblet, Margarita Diaz Pedrero, Jorge Fernandez Alonso, Rocio Cabrera" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Carmen" "apellidos" => "Martin Herrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Marta" "apellidos" => "Suñer Poblet" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "nombre" => "Margarita" "apellidos" => "Diaz Pedrero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "nombre" => "Jorge" "apellidos" => "Fernandez Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "nombre" => "Rocio" "apellidos" => "Cabrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicios de Nefrología, Hospital Universitario Virgen del Rocío, Sevilla, Sevilla, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicios de Anatomía Patológica, Hospital Universitario Virgen del Rocío, Sevilla, Sevilla, España, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad por depósito de cadenas ligeras. Experiencia en nuestro medio." ] ] "textoCompleto" => "INTRODUCTION <br></br><br></br>B-cell proliferative diseases are usually associated to production and secretion into blood of a monoclonal immunoglobulin, or a fragment of it, that may be deposited in the organs in an organized form as crystals, fibrils or microtubules, or in a non-organized  form  (granular).  This  immunoglobulin  will mainly be deposited in the kidney, not only because this is a highly vascularized organ, but also because  the  renal  tubule has  a  predominant  role  in  immunoglobulin  metabolism.1 Diagnosis of renal involvement due to immunoglobulin deposition is being expanded with development and routine implementation  of  different  laboratory  procedures  (staining  with <br></br>antibodies specific to kappa and lambda light chains, electron microscopy study, development of procedures with an increasing  sensitivity  for  detecting  the monoclonal  component  in blood  or  urine).2 Light  chain  deposition  disease  (LCDD)  is characterized  by  generalized  deposition  of  a  single  type  of light  chain  along  the  renal  basement  membrane.  LCDD  is usually  reported  to  occur  during  plasma  cell  dyscrasia  or another  lymphoproliferative disorder, but may  also occur  in the absence of any hematological disorder, in which case it is <br></br>called idiopathic LCDD. Severe renal insufficiency occurs in most patients despite  treatment.3,4 The most  typical  renal  lesion is nodular glomerulosclerosis, in which mesangial nodules and deposition of a single chain type occur along the glomerular  basement  membrane.  However,  diagnosis  will  be based  on  light  chain  deposition  along  the  tubular  basement membrane. The aim of this study was to review our experience with this uncommon disease. <br></br><br></br>MATERIALS AND METHODS <br></br><br></br>Cases  of  LCDD  diagnosed  at  our  hospital  among  all  adult biopsies performed  in  the 1978-2005 period were  analyzed. Clinical and pathological data and patient course were studied based on clinical records and on the information provided by physicians with whom the patient was in direct contact at the time of study closure. All renal biopsies taken during the abovementioned  period were  read  by  the  same  pathologist. All samples  diagnosed  as  LCDD  had  been  processed  for  study with  light microscopy  (LM)  and  immunofluorescence  (IF). <br></br>Samples from five patients were also analyzed using electron microscopy  (EM). Diagnosis  of LCDD was made  by  an  IF study, in which sera against kappa and lambda light chains are used. This procedure has been routinely performed at our hospital since 2002. The presence of nodular glomerulosclerosis, chain  deposit  distribution,  thickening  of  basement membranes, extent of tubulointerstitial involvement, and the presence of  associated  renal  involvement  from  myeloma  kidney  are analyzed. Acute  renal  failure  (ARF)  or  rapidly  progressive renal  insufficiency  (RPRI)  was  defined  as  the  presence  of renal  failure at  the  time of  renal biopsy with a normal prior renal function or a doubling of basal creatinine in a short time period (less than 30 days). Patients who had known renal damage  for  a  period  longer  than  30  days with  renal  function data similar to those found at diagnosis and patients with ultrasonographically  small  and  poorly  differentiated  kidneys were  diagnosed  chronic  renal  failure  (CRF).  Screening  for plasma  cell  dyscrasia  was  based  on  previously  established <br></br>criteria.5 Bone marrow cellularity was studied in five patients, and  flow cytometry was also performed  in  two of  these patients.   Blood  electrophoresis was performed  in  all patients, and  light  chains were  studied  in  the  urine  of  five  of  them using  nephelometry.  Immunofixation  in  blood  or  urine was not available  in any case. Patients with clinical data suggesting involvement of other organs were considered to have extrarenal involvement due to light chain deposition. <br></br><br></br>RESULTS <br></br><br></br>Six cases of LCDD, all of them diagnosed in the 1999-2005 period, were identified in four female and two male patients with a mean age of 57 years (range, 37-74). All patients had advanced  renal  failure  and  proteinuria  at  diagnosis,  with mean plasma creatinine levels of 4.3 ± 1.59 mg/dL and proteinuria of 4.3 ± 1.7 g/24 h. Four patients (66%) showed acute or rapidly progressive renal damage, and two patients had chronic renal failure. Blood electrophoresis detected no monoclonal peaks in any case. Hypogammaglobulinemia was found in 5 patients (83.3%). In a patient, light chain study in urine showed a selective elevation of the kappa light chain suggesting a monoclonal peak (this patient was subsequently diagnosed of myeloma).  <br></br><br></br>Bone marrow was studied in 5 patients. Of these, three patients were  diagnosed  of myeloma,  two  based  on  the  bone marrow study and one on the lytic images seen. All bone marrow aspirates showed a proportion of plasma cells lower than 10%,  and  myeloma  was  diagnosed  based  on  a  cytometry study in the two patients in whom this was performed. LCDD was the first sign of the disease in all 3 patients with myeloma. No evidence of myeloma or other plasma cell dyscrasia was found in 3 patients. <br></br><br></br>Table I shows the characteristics of renal biopsies. They all showed  thickening  and  kappa  chain  deposits  in  the  tubular basement membrane. A nodular  pattern  (fig.  1) with  kappa chain  deposition  in  GBM,  Bowman¿s  capsule,  and  mesangium  (fig. 2), was seen in 5 patients (83.3%). A patient showed  tubulointerstitial  involvement with  lymphoplasmocytic infiltrate in interstitium and casts with peripheral cellular reaction  and  kappa  chain  deposition  in  casts  and  TBM. <br></br><br></br>Hemodialysis had  to be started  in 5 patients (4 with ARF or RPRI and one with CRF). Two of  these patients had myeloma. Mean time from diagnosis to start of dialysis was 46 days (range, 0-180). In patients diagnosed of myeloma and idiopathic LCDD, times to start of dialysis were 96 days (range, 13-180) and 7 days (range, 0-13) respectively. Apatient had heart failure  and  episodes  of  paroxysmal  atrial  fibrillation  with echocardiographic (left ventricular hypertrophy) and electrocardiographic  (relative  microvoltage)  evidence  suggesting cardiac involvement from immunoglobulin deposit. <br></br><br></br>Three  patients were  given  immunosuppressive  treatment. Two  patients  diagnosed  of  myeloma  received  VAD  cycles (vincristine,  adriamycin,  dexamethasone),  and  one  patient with  idiopathic LCDD was  treated with corticosteroids. The third patient diagnosed of myeloma died 15 days after admission from an infectious complication and did not receive chemotherapy. The patient with idiopathic LCDD was treated for only  four months  because  she  developed  catheter-induced bacteremia  that  required  corticosteroid  discontinuation.  She died at two years of follow-up. <br></br><br></br>Follow-up  time  from  diagnosis  to  death  or  study  closure was highly variable (15 days-59 months), with a mean of 27 months. Mean follow-up time was 15 months in myeloma patients (15 days-40 months) and 38 months (26-54 months) in idiopathic LCDD. Of the 4 patients who died (66.6%), 2 had myeloma. Mean survival of myeloma patients was 13 weeks (one died at 15 days and the other at six months), as compared to a mean survival of 110 weeks in patients with idiopathic  LCDD  (one  died  at  26  months  and  the  other  at  29 months). <br></br><br></br>Two  of  the  6  patients  studied,  one  diagnosed  idiopathic LCDD and the other myeloma, were still alive at study closure. The patient diagnosed of  idiopathic LCDD  continues on dialysis after almost 5 years of follow-up, has not experienced involvement of other organs or a malignant hematological disease, and is in a waiting list for receiving a kidney transplant, though  indication  of  this  treatment  is  doubtful  according  to some authors.6,7 The myeloma patient has a stable renal function after receiving chemotherapy, with no requirement of replacement therapy after 40 months of follow-up. <br></br><br></br>DISCUSSION <br></br><br></br>Necropsy studies in myeloma patients have found renal involvement  by LCDD  in  5%  of  cases. However,  the  frequency with which  the disease  is diagnosed  is much  lower.8 All our cases were diagnosed from 1999 to 2005 among the total 640 renal  biopsies  performed  during  this  period,  representing  a LCDD  rate of 1%, greater  than  reported  in other series.8,9 In our analysis, LCDD was more frequent in females and occurred  in middle-aged people,  though  it cannot be ruled out  in young people. <br></br><br></br>Unlike  the  findings  in  other  series,  a  monoclonal  peak could  not  be  detected  in  blood  or  urine  from  any  patient, which may possibly be related  to  the sensitivity of  the diagnostic procedures used. Hence, blood and urine immunofixation should be requested, either routinely or if a strong clinical  suspicion  exists,  even  if  electrophoresis  is  normal. However, even sensitive procedures such as immunofixation are  not  able  to  detect  a monoclonal  peak  in  up  to  30%  of cases. Renal biopsy therefore plays an essential role in diagnosis of LCDD and its associated dysproteinemia, as evidenced by this and other studies.10 Most of our patients had hypogammaglobulinemia  and  albuminuria,  and  these  findings should therefore lead to suspect some form of immunoglobulin deposition disease, as suggested by other studies.11,12 Clinically, LCDD started in most of our patients as an ARF/RPRI associated  to  nephrotic  proteinuria.  Since  no  monoclonal peak was  detected  in  blood  and  urine  from  any  of  our  patients, LCDD should also be suspected  in  the event of  renal failure and proteinuria of an unknown origin. Renal biopsy is required for diagnosis. <br></br><br></br>In all our patients, the chain deposited in the kidney was of the  kappa  type.  This  is  the  chain  primarily  deposited  in LCDD  according  to  all  series, unlike  in  amyloidosis, where the lambda chain is deposited.13,14 The classical pattern of nodular  glomerulosclerosis was  found  in most  of  our  biopsies (83%),  and  tubulointerstitial  involvement  alone, with  lymphoplasmocytic infiltration, occurred in one patient. Bone marrow study is not always diagnostic, and routine staining with anti-kappa and anti-lambda sera would therefore be required to prevent the disease from being undiagnosed. <br></br><br></br>Diagnosis of myeloma may be made with a flow cytometry study,5 but as this analysis is not performed in many hospitals, marrow  cellularity  continues  to be  a diagnostic  criterion  together with the monoclonal peak in blood or urine and involvement  of  other  organs.  The  proportion  of  plasma  cells  in bone marrow was  not  higher  than  10%  in  none  of  our  patients, so  that  if  this criterion  is applied, myeloma diagnosis may  be  delayed. Thus, when  plasma  cell  dyscrasia  such  as LCDD  is  strongly  suspected,  plasma  cell  phenotype would have to be determined to rule out a hematological tumor pathology. This happened with one of our patients, who underwent two bone marrow aspirations with a one month interval. Cellularity was similar in both samples (5%), but flow cytometry performed in the second aspirate provided a diagnosis of myeloma. <br></br><br></br>Dialysis  requirements  were  high  (83%)  for  the  whole group, but particularly for patients with idiopathic LCDD, all of whom required dialysis and at an earlier time than the myeloma group. <br></br><br></br>Chemotherapy,  which  is  unquestionable  in myeloma  patients, is controversial when no malignant disease exists. However, general practice has consisted of treatment with corticosteroids  plus  melphalan,  regardless  of  the  associated hematological disease, although myeloma patients more  frequently receive VAD cycles, which appear to have a protective effect upon patient survival.15-18 Recent studies showed disappearance  of  light  chain  deposits  in  the  kidney  after treatment with  chemotherapy  and bone marrow  transplantation,17,19 which  would  support  intensive  therapy  in  patients with LCDD. Two of our myeloma patients received VAD cycles, and renal function improvement was achieved in one of them. <br></br><br></br>Mortality was high in our patients. The same number of patients died in the myeloma and the idiopathic LCDD groups, but the mean follow-up time from diagnosis to death was longer  in  patients  with  idiopathic  LCDD  (110  vs 13  weeks). This,  combined  with  the  longer  follow-up  time  in  patients with  idiopathic LCDD  (38  vs 15 months),  suggests  that  the presence of myeloma in the setting of LCDD shortens patient survival, as seen in other series (20), though there are reports that do not support these data (4,6). <br></br><br></br>To  sum  up,  the  number  of  patients  with  a  diagnosis  of LCDD detected in our series was higher than expected according to literature. Wider studies would be required to confirm these results. LCDD was associated to a myeloma in half of our  patients,  and  its  first  manifestation  was  renal  involvement. The predominant clinical sign was acute renal function impairment with nephrotic proteinuria  that required dialysis. The  structural  lesion most  commonly  associated  is  nodular glomerulosclerosis. Renal and patient survival was poor. <br></br>" "pdfFichero" => "P-E-S-A360-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec440713" "palabras" => array:1 [ 0 => "Gammapatía monoclonal" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec440715" "palabras" => array:1 [ 0 => "Discrasia de células plasmáticas" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec440717" "palabras" => array:1 [ 0 => "Glomeruloesclerosis nodular" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec440719" "palabras" => array:1 [ 0 => "Nefropatía por cadenas ligeras" ] ] ] "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440714" "palabras" => array:1 [ 0 => "Monoclonal gammopathies" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440716" "palabras" => array:1 [ 0 => "Plasma cell dyscrasia" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440718" "palabras" => array:1 [ 0 => "Nodular sclerosing glomerulopathy" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440720" "palabras" => array:1 [ 0 => "Light chain nephropathy" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "La enfermedad por depósito de cadenas ligeras (EDCL) es una entidad rara, caracterizada por el depósito de un solo tipo de cadena ligera en la membrana basal del riñón. Puede asociarse a una discrasia de células plasmáticas, aunque en ocasiones no se detecta patología hematológica y se denomina idiopática. Suele manifestarse como una insuficiencia renal severa con proteinuria nefrótica, no tiene tratamiento claramente establecido y el pronóstico es malo. El objetivo de este trabajo es analizar las características de los casos de EDCL diagnosticados en nuestro medio. Se identifican 6 casos, todos entre 1999 y 2005 de un total de 640 biopsias realizadas en ese periodo, 4 mujeres y 2 varones, media de 57 años. Se detectó un mieloma en 3 pacientes (50%). La insuficiencia renal aguda o de rápida evolución fue la presentación clínica más frecuente (66%) junto con proteinuria nefrótica (66%). Todas las biopsias mostraban engrosamiento de la membrana basal tubular y depósito lineal de cadenas kappa en la misma. La lesión glomerular más frecuente fue la glomeruloesclerosis nodular (83%). En un caso la afectación fue exclusivamente túbulo intersticial con cilindros tubulares asociados. Se trataron 3 pacientes, 2 con mieloma. Requirieron diálisis 5 pacientes: 3 con EDCL idiopática con un tiempo medio desde el diagnóstico hasta recibir la misma de 7 días, y 2 con mieloma que tardaron una media de 46 días en requerir diálisis. Fallecieron 4 pacientes, 2 con mieloma. El tiempo de seguimiento hasta el exitus fue de 13 semanas para los pacientes con mieloma y de 110 semanas para el resto. Conclusión, la EDCL parece mas frecuente de lo publicado y se asocia a mieloma en la mitad de los casos. Se presenta con daño renal severo y la evolución renal y del paciente es mala. " ] "en" => array:1 [ "resumen" => "The Light chain deposition disease (LCDD) is a strange entity characterised by the deposition of only one type of light chain in the renal tubular basement membranes. It can be associated to a plasma cell dyscrasia, however, it can occur in the absence of any detectable hematological disorder and it is called idiopathic LCDD. The clinical manifestation is renal insufficiency and nephrotic proteinuria, it does not have a clearly fixed treatment and has a severe prognosis. The aim of this work is to analyse the characteristics of the LCDD cases diagnosed within our environment. Six cases were identified, all of them between 1999 and 2005, from a total amount of 640 renal biopsies performed during this period, 4 women and 2 men, average age of 57. Multiple myeloma in 3 patients was detected (50%). The acute renal failure or rapidly progressive renal insufficiency was the most frequent clinical presentation (66%) together with nephrotic proteinuria (66%). All the biopsies showed tubular basement membranes thickening and kappa chains with a linear distribution within the same. The most frequent glomerular pathological finding was the nodular sclerosing glomerulopathy (83%). In one of the cases the affectation was exclusively tubular interstitial with tubular casts. 3 patients were treated, 2 with multiple myeloma. 5 patients needed dialysis: 3 with idiopathic LCDD within an average time of 7 days from the diagnosis to its reception, and 2 with myeloma, who started needing dialysis in an average of 46 days. 4 patients died, 2 of them with myeloma. The monitoring time until the death was 13 weeks for the patients with myeloma and 110 weeks for the rest. Conclusion: The LCDD seems to be more frequent than what has been published and it is associated to the myeloma in half of the cases. It appears together with severe renal insufficiency and the patient¿s and renal prognosis is poor." ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002800000005/v0_201502091635/X2013251408003928/v0_201502091635/en/main.assets" "Apartado" => array:4 [ "identificador" => "35441" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002800000005/v0_201502091635/X2013251408003928/v0_201502091635/en/P-E-S-A360-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408003928?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 9 | 13 |
| 2024 October | 49 | 57 | 106 |
| 2024 September | 40 | 48 | 88 |
| 2024 August | 63 | 70 | 133 |
| 2024 July | 46 | 39 | 85 |
| 2024 June | 75 | 43 | 118 |
| 2024 May | 67 | 59 | 126 |
| 2024 April | 53 | 48 | 101 |
| 2024 March | 51 | 42 | 93 |
| 2024 February | 33 | 47 | 80 |
| 2024 January | 36 | 32 | 68 |
| 2023 December | 60 | 33 | 93 |
| 2023 November | 42 | 53 | 95 |
| 2023 October | 48 | 36 | 84 |
| 2023 September | 62 | 32 | 94 |
| 2023 August | 35 | 25 | 60 |
| 2023 July | 50 | 33 | 83 |
| 2023 June | 37 | 47 | 84 |
| 2023 May | 60 | 35 | 95 |
| 2023 April | 46 | 39 | 85 |
| 2023 March | 50 | 19 | 69 |
| 2023 February | 47 | 19 | 66 |
| 2023 January | 40 | 27 | 67 |
| 2022 December | 40 | 38 | 78 |
| 2022 November | 45 | 27 | 72 |
| 2022 October | 36 | 44 | 80 |
| 2022 September | 45 | 29 | 74 |
| 2022 August | 41 | 38 | 79 |
| 2022 July | 35 | 53 | 88 |
| 2022 June | 39 | 38 | 77 |
| 2022 May | 34 | 43 | 77 |
| 2022 April | 47 | 51 | 98 |
| 2022 March | 61 | 55 | 116 |
| 2022 February | 43 | 48 | 91 |
| 2022 January | 43 | 33 | 76 |
| 2021 December | 55 | 42 | 97 |
| 2021 November | 31 | 43 | 74 |
| 2021 October | 57 | 51 | 108 |
| 2021 September | 31 | 34 | 65 |
| 2021 August | 38 | 30 | 68 |
| 2021 July | 55 | 39 | 94 |
| 2021 June | 32 | 23 | 55 |
| 2021 May | 71 | 32 | 103 |
| 2021 April | 93 | 70 | 163 |
| 2021 March | 82 | 27 | 109 |
| 2021 February | 121 | 19 | 140 |
| 2021 January | 43 | 23 | 66 |
| 2020 December | 43 | 13 | 56 |
| 2020 November | 56 | 24 | 80 |
| 2020 October | 45 | 11 | 56 |
| 2020 September | 45 | 14 | 59 |
| 2020 August | 50 | 9 | 59 |
| 2020 July | 55 | 9 | 64 |
| 2020 June | 45 | 14 | 59 |
| 2020 May | 46 | 9 | 55 |
| 2020 April | 31 | 21 | 52 |
| 2020 March | 51 | 10 | 61 |
| 2020 February | 37 | 16 | 53 |
| 2020 January | 54 | 18 | 72 |
| 2019 December | 57 | 32 | 89 |
| 2019 November | 69 | 20 | 89 |
| 2019 October | 25 | 11 | 36 |
| 2019 September | 42 | 13 | 55 |
| 2019 August | 31 | 26 | 57 |
| 2019 July | 60 | 22 | 82 |
| 2019 June | 50 | 15 | 65 |
| 2019 May | 56 | 20 | 76 |
| 2019 April | 116 | 26 | 142 |
| 2019 March | 38 | 18 | 56 |
| 2019 February | 43 | 20 | 63 |
| 2019 January | 52 | 26 | 78 |
| 2018 December | 70 | 39 | 109 |
| 2018 November | 81 | 17 | 98 |
| 2018 October | 64 | 20 | 84 |
| 2018 September | 61 | 16 | 77 |
| 2018 August | 51 | 23 | 74 |
| 2018 July | 51 | 21 | 72 |
| 2018 June | 38 | 11 | 49 |
| 2018 May | 36 | 18 | 54 |
| 2018 April | 41 | 9 | 50 |
| 2018 March | 39 | 10 | 49 |
| 2018 February | 39 | 7 | 46 |
| 2018 January | 30 | 9 | 39 |
| 2017 December | 33 | 8 | 41 |
| 2017 November | 39 | 9 | 48 |
| 2017 October | 40 | 11 | 51 |
| 2017 September | 43 | 9 | 52 |
| 2017 August | 39 | 12 | 51 |
| 2017 July | 38 | 15 | 53 |
| 2017 June | 40 | 13 | 53 |
| 2017 May | 48 | 16 | 64 |
| 2017 April | 41 | 13 | 54 |
| 2017 March | 34 | 16 | 50 |
| 2017 February | 31 | 10 | 41 |
| 2017 January | 15 | 12 | 27 |
| 2016 December | 68 | 12 | 80 |
| 2016 November | 61 | 13 | 74 |
| 2016 October | 71 | 12 | 83 |
| 2016 September | 127 | 12 | 139 |
| 2016 August | 225 | 18 | 243 |
| 2016 July | 171 | 11 | 182 |
| 2016 June | 132 | 0 | 132 |
| 2016 May | 121 | 0 | 121 |
| 2016 April | 101 | 0 | 101 |
| 2016 March | 89 | 0 | 89 |
| 2016 February | 84 | 0 | 84 |
| 2016 January | 80 | 0 | 80 |
| 2015 December | 95 | 0 | 95 |
| 2015 November | 89 | 0 | 89 |
| 2015 October | 77 | 0 | 77 |
| 2015 September | 76 | 0 | 76 |
| 2015 August | 71 | 0 | 71 |
| 2015 July | 73 | 0 | 73 |
| 2015 June | 39 | 0 | 39 |
| 2015 May | 60 | 0 | 60 |
| 2015 April | 5 | 0 | 5 |
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