Dialysis dose measurements of Kt by ionic dialisance reveals less dialysis adequacy than the Kt/VUREA-based method in critically ill patients with acute renal failure
La medida de la dosis de diálisis mediante Kt por dialisancia iónica revela una menor adecuación que la medida por Kt/VUREA en la insificiencia renal aguda de pacientes críticos
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Serra Cabañas, X. Barros Freiría, J. Garro Martínez, M. Blasco Pelicano, F. Maduell Canals, A. Torras Rabasa, Esteban Poch López de Briñas" "autores" => array:7 [ 0 => array:3 [ "Iniciales" => "N." "apellidos" => "Serra Cabañas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "X." "apellidos" => "Barros Freiría" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "J." "apellidos" => "Garro Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "M." "apellidos" => "Blasco Pelicano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "F." "apellidos" => "Maduell Canals" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 5 => array:3 [ "Iniciales" => "A." "apellidos" => "Torras Rabasa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 6 => array:4 [ "nombre" => "Esteban" "apellidos" => "Poch López de Briñas" "email" => array:1 [ 0 => "epoch@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología y Trasplante Renal, Hospital Clínic. IDIBAPS. Universitat de Barcelona, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La medida de la dosis de diálisis mediante Kt por dialisancia iónica revela una menor adecuación que la medida por Kt/VUREA en la insificiencia renal aguda de pacientes críticos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10336108_a14_t1.jpg" "Alto" => 369 "Ancho" => 535 "Tamanyo" => 36883 ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the included patients and haemodialysis sessions." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION </span></p><p class="elsevierStylePara">Acute renal failure (ARF) is a frequent complication in critical patients (with an incidence rate of between 5 and 25%), and it increases mortality significantly, particularly in cases that require renal replacement therapy, for which mortality can reach rates between 50 and 70%.<span class="elsevierStyleSup">1 </span>There is no agreement whether the intermittent haemodialysis (IHD) dose for ARF in the critical patient is positively linked to survival. A study published in 2002 indicated that daily dialysis improved survival and accelerated renal recovery,<span class="elsevierStyleSup">2 </span>although this idea was refuted in a very large study published recently.<span class="elsevierStyleSup">3 </span>One of the criticisms of the first study was that mean Kt/V<span class="elsevierStyleSup">UREA </span>supplied per session was only 0.94, compared with 1.3 in the second study. From these studies and others, we deduce that there is a minimum effective dose that should be reached, and that a regimen based on IHD lasting four to five hours on alternate days has a similar mortality to regimens with a higher frequency, provided that the dose administered per session is appropriate. The problem with calculating the dialysis dose in a critical patient is that no method has been validated to date. V<span class="elsevierStyleSup">UREA </span>is difficult to estimate in acute patients, and therefore Kt/V<span class="elsevierStyleSup">UREA</span>, which has been thoroughly validated for calculating IHD doses in ARF patients, should not be used for patients in critical condition. Although this is well-known, the ADQI (Acute Dialysis Quality Initiative) recommendations are based on the Kt/V<span class="elsevierStyleSup">UREA 4 </span>method, which is used in most important studies.<span class="elsevierStyleSup">2,3 </span>In recent years, one method for measuring IHD dose, ionic dialysance (ID) has been validated for CRF.<span class="elsevierStyleSup">5 </span>The study is based on continuous monitoring of the dialysate conductivity which some haemodialysis monitors measure automatically. Recently, one study used this method in critical patients with ARF and compared it with the gold standard method of fractional dialysate sampling, which showed excellent correlation (0.96) between Kt<span class="elsevierStyleSup">ID </span>and Kt<span class="elsevierStyleSup">dialysate</span>. <span class="elsevierStyleSup">6 </span>The main objective of the present study was to evaluate application of the Kt<span class="elsevierStyleSup">ID </span>measurement in normal clinical practice and compare it with the Kt/V<span class="elsevierStyleSup">UREA </span>method, thus evaluating the prevalence of adequate dialysis in critical patients with ARF. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHODS </span></p><p class="elsevierStylePara">This prospective observational study was carried out in Hospital Clínic of Barcelona between September 2007 and June 2009. It includes all critical patients with ARF on renal replacement therapy with intermittent haemodialysis in a standard regimen of sessions lasting at least three hours every 48 hours who were treated by our service during that period. Vascular access consisted of a percutaneous 11.5 F catheter that was either femoral (24cm long) or jugular (15 or 20cm long depending on whether it was on the right or left, respectively). The dialysis characteristics were identical in all patients and similar to the treatment systematically applied in our centre: Fresenius 4008S monitor, frequency of every 48 hours, duration four hours, FX 60 membrane (Fresenius, surface area 1.4m<span class="elsevierStyleSup">2 </span>), blood flow of 250ml/min, dialysate flow 500ml/min, conductivity value of 14.5mS/cm and dialysate temperature of 35-36º C. In all dialysis sessions, Kt was determined using ID (Kt<span class="elsevierStyleSup">ID</span>) and during the first three IHD sessions indicated in each patient, we determined Kt/V<span class="elsevierStyleSup">UREA </span>by the Daugirdas<span class="elsevierStyleSup">7 </span>method. In addition, we registered several variables that may affect the administered dialysis dose, such as the need for vasoactive drugs, mechanical ventilation, septic shock, catheter dysfunction requiring reversal of the arterial and venous lines, and episodes of hypotension during the session defined as a drop of 20mmHg in systolic pressure after beginning the dialysis or a need to increase the dose of vasoactive drugs.</p><p class="elsevierStylePara"> <span class="elsevierStyleBold">Statistical analysis </span></p><p class="elsevierStylePara">Statistical analysis was performed using SPSS software, version 15.0 (Chicago, USA). Values are expressed as a mean ± standard error of the mean (SEM). Comparison of means was performed using Student’s t-test or nonparametric tests for variables without a normal distribution. Qualitative variables were compared using Chi-squared test. Statistical significance was established for p-values < 0.05. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara">The study included 17 critical patients with ARF (six men and eleven women) with a mean age of 61.7 ± 3.7 years. Five of them were admitted to the ICU due to septic shock. Six patients were treated with invasive mechanical ventilation, and three required treatment with vasoactive drugs (noradrenaline or dopamine) in low doses (table 1). The characteristics of the dialysis sessions corresponded with the guidelines for the present study (table 1). The mean Kt/V<span class="elsevierStyleSup">UREA </span>per session was 1.19 ± 0.14; 59% of the sessions had a value higher than that recommended by ADQI (1.2 or higher, regardless of sex), with 50% of men and 63.3% of women receiving the minimum required dose (figure 1). Meanwhile, the mean Kt<span class="elsevierStyleSup">ID </span>was 37.6 ± 1L, and the minimum recommended Kt<span class="elsevierStyleSup">ID </span>was reached in only 29.48 of the sessions (40L for women and 45L for men). Mean Kt<span class="elsevierStyleSup">ID </span>values were 37.5 ± 1.5L for men and 37.6 ± 1.3L in women. If we consider the Kt<span class="elsevierStyleSup">ID </span>values recommended for patients with chronic renal failure (CRF) according to Lowrie et al<span class="elsevierStyleSup">8 </span>(Kt<span class="elsevierStyleSup">ID </span>between 45 and 50L for men and Kt<span class="elsevierStyleSup">ID </span>between 40 and 45L for women), recommendations were only met in 42.4% of all sessions for women and 5.6% of sessions for men (figure 1). There were no significant differences in the mean Kt/V<span class="elsevierStyleSup">UREA </span>or mean Kt<span class="elsevierStyleSup">ID </span>among patients grouped according to sex, need for vasoactive drugs, presence of septic shock, prior history of CRF, need for mechanical ventilation or hypotension episodes (data not shown). In sessions in which catheter dysfunction led to line reversal, values of KT/V<span class="elsevierStyleSup">UREA </span>(0.84 ± 0.27 compared to 1.27 ± 0.16) and Kt<span class="elsevierStyleSup">ID </span>(32 ± 1 compared to 37 ± 1.8) were numerically lower, but the difference did not reach a statistically significant level (p = 0.28 and p = 0.22, respectively). </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">In this study, we evaluated the dialysis dose administered to a group of ARF patients in critical condition and compared the dialysis adequacy between direct measurement using Kt<span class="elsevierStyleSup">ID </span>and Kt/V<span class="elsevierStyleSup">UREA</span>, the classical method which is still being recommended. We observed that use of Kt<span class="elsevierStyleSup">ID </span>can identify the patient subgroup which appears to receive an adequate dose of dialysis according to the Kt/V<span class="elsevierStyleSup">UREA</span>measurement, but which could be considered as underdialysed. This observation concurs with that of a recent study of CRF patients in which the Kt<span class="elsevierStyleSup">ID </span>value identified between 30 and 40% of the patients as underdialysed, although they met the minimum dosage of 1.3 recommended for CRF according to the Kt/V<span class="elsevierStyleSup">UREA </span>measurement.<span class="elsevierStyleSup">9 </span>Furthermore, among the ARF patients we see a low percentages of compliance with one method or another, which points to the need to focus our efforts on using a reliable, easy method for calculating the proper dose in these patients whose mortality rate is high. Although there have recently been doubts about the correlation between dialysis doses and survival in ARF,<span class="elsevierStyleSup">2,3 </span>it is true that there is a minimum dialysis dose in this patient group, established as a Kt/V<span class="elsevierStyleSup">UREA </span>level of 1.2 which is partly based on recommendations for CRF patients.<span class="elsevierStyleSup">4,10 </span>However, specific studies in ARF patients will be necessary in order to determine the minimum effective dose. In any case, we know that this measurement is not transferrable to this type of patients who are not in a state of metabolic equilibrium and have an elevated protein catabolism, changing volaemic states, possible residual renal function, and in whom the estimated urea distribution volume (V<span class="elsevierStyleSup">UREA</span>) is uncertain. Therefore, while V<span class="elsevierStyleSup">UREA </span>may be inferred from total body water volume in healthy individuals or those with CRF, it has been observed between 7 and 50% higher in acute patients.<span class="elsevierStyleSup">11 </span>Underdialysis is common in ARF. Moreover, a study in ARF patients showed that 70% of the treatments provided a Kt/V<span class="elsevierStyleSup">UREA </span>value below 1.2, and that patient weight, sex and blood flow affected the resulting dose.<span class="elsevierStyleSup">12 </span>Various factors are involved in each haemodialysis session, and they may affect dialysis effectiveness. It therefore seems logical that control systems were created to measure the dose the patient receives each session, in real time. At present, different monitors include biosensors that use the machine’s own conductivity probes to provide non-invasive measurements of the effective ionic dialysance, equivalent to urea clearance (K). This enables us to calculate the dialysis dose without a work overload or analytical measurements, and at no additional cost.<span class="elsevierStyleSup">13-15 </span>Using Kt has its advantages. Both K and t are real measurements from the monitor, cannot be manipulated by the user and may be used in all dialysis sessions. Initial recommendations in 1999 were based on a minimum Kt of 40 to 45L for women and 45 to 50L for men with CRF<span class="elsevierStyleSup">8</span>. These indications were subsequently validated,<span class="elsevierStyleSup">16 </span>and it was observed that patient group receiving between 4 and 7 litres less than the prescribed amount experienced a 10% increase in mortality; the group receiving between 7 and 11 litres less experienced a 25% increase; and the group with 11 or more litres less than the prescribed amount experienced a 30% increase. SEN (Spanish Association of Nephrology) guidelines recommend a minimum of 45L of Kt for CRF patients who have ionic dialysance monitors.<span class="elsevierStyleSup">17,18 </span>There is no minimum recommended dose of Kt<span class="elsevierStyleSup">ID </span>in ARF, and no data about its effect on mortality, which is why we have taken the recommendations for CRF in the lowest value in the range. The main advantage of measuring Kt<span class="elsevierStyleSup">ID </span>automatically is that it permits us to adapt the conditions of each dialysis session in order to reach the optimal dose. On this topic, a recent study showed that in patients equipped with catheters in the haemodialysis programme, it was necessary to prolong the dialysis session by 30 minutes in order to reach target Kt, compared with patients with an arteriovenous fistula (IAVF).<span class="elsevierStyleSup">19 </span>Although systematically prolonging dialysis sessions (to five hours, for example) in all acute patients is not an uncommon practice, it is true that this measurement is not always necessary<span class="elsevierStyleSup">3 </span>and, in this sense, continuous Kt<span class="elsevierStyleSup">ID </span>monitoring may help in adapting session length in order to reach the minimum recommended dose. In conclusion, measuring the dialysis dose using the Kt<span class="elsevierStyleSup">ID </span>method identifies a higher number of inadequate sessions than the standard Kt/V<span class="elsevierStyleSup">UREA </span>method does, and the former therefore appears to be a useful method for delivering a minimum dialysis dose in ARF patients. </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements </span></p><p class="elsevierStylePara">The authors would like to thank the Grupo de Trabajo del Enfermo Crítico (Critically Ill Patients Study Group) at Hospital Clínic of Barcelona for its contributions to the completion of this study. The study was funded in part by FIS PI0800140 and ISCIII-Retic-RD06, REDinREN (16/06). </p><p class="elsevierStylePara"><a href="grande/10336108_a14_t1.jpg" class="elsevierStyleCrossRefs"><img src="10336108_a14_t1.jpg" alt="Clinical characteristics of the included patients and haemodialysis sessions."></img></a></p><p class="elsevierStylePara">Table 1. Clinical characteristics of the included patients and haemodialysis sessions.</p><p class="elsevierStylePara"><a href="grande/10336108_a14_f1.jpg" class="elsevierStyleCrossRefs"><img src="10336108_a14_f1.jpg" alt="Percentages of haemodialysis sessions that met the proposed minimum criteria (Kt/VUREA >_40_1.2 for women; KtID >_45 for men)."></img></a></p><p class="elsevierStylePara">Figure 1. Percentages of haemodialysis sessions that met the proposed minimum criteria (Kt/VUREA >_40_1.2 for women; KtID >_45 for men).</p>" "pdfFichero" => "P1-E47-S1878-A10336-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437515" "palabras" => array:1 [ 0 => "Hemodiálisis" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437517" "palabras" => array:1 [ 0 => "Insuficiencia renal aguda" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437519" "palabras" => array:1 [ 0 => "Dialisancia iónica" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec437521" "palabras" => array:1 [ 0 => "Dosis de diálisis" ] ] ] "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437516" "palabras" => array:1 [ 0 => "Hemodialysis" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437518" "palabras" => array:1 [ 0 => "Acute renal failure" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437520" "palabras" => array:1 [ 0 => "Ionic dialysance" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec437522" "palabras" => array:1 [ 0 => "Dialysis dose" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Introduction: </span></span><span class="elsevierStyleItalic">Measurement of dialysis dose by methods based on urea kinetics (Kt/V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">UREA</span></span><span class="elsevierStyleItalic">) are hardly applicable to critical ill patients with acute renal failure (ARF). However, it is the base of the ADQI consensus recommendation for the target minimum dose. </span><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Objetive: </span></span><span class="elsevierStyleItalic">To evaluate the usefulness of the real-time measurement of delivered dialysis dose (Kt) by means of the ionic dialysance (KtID) in the critically ill patient and to compare adequacy of dialysis dose between KtID and traditional Kt/V</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">UREA</span></span><span class="elsevierStyleItalic">. </span><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Material and methods: </span></span><span class="elsevierStyleItalic">Prospective observational study in 17 critically ill patients with ARF requiring acute hemodialysis with a predefined prescription for the study (51 measures). </span><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Results: </span></span><span class="elsevierStyleItalic">The mean delivered Kt/V</span><span class="elsevierStyleItalic"><span class="elsevierStyleInf">UREA</span> </span><span class="elsevierStyleItalic">was 1.19 ± 0.14, with 59% of the sessions with values equal or above the ADQI recommendation. On the contrary, the mean KtID values obtained was 37.6 ± 1 l, with only 29.4% of the sessions being equal or greater than the recommended values. </span><span class="elsevierStyleBold"><span class="elsevierStyleItalic">Conclusions: </span></span><span class="elsevierStyleItalic">Dialysis dose monitoring by means of KtID reveals a lower degree of adequacy as compared to the traditional Kt/V</span><span class="elsevierStyleItalic"><span class="elsevierStyleInf">UREA</span> </span><span class="elsevierStyleItalic">method. The dynamic character of KtID monitoring can allow the adaptation of each dialysis sessions («K» and/or «t») in order to achieve the recommended dose.</span></p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducción: </span>La medida de la dosis de hemodiálisis basada en la cinética de la urea (Kt/V<span class="elsevierStyleInf">UREA</span>) adolece de problemas de aplicabilidad en el paciente crítico con insuficiencia renal aguda (IRA). No obstante, las recomendaciones de consenso sobre la dosis se basan en el Kt/VUREA. <span class="elsevierStyleBold">Objetivo: </span>Evaluar la utilidad de la medida en tiempo real de la dosis de diálisis suministrada (Kt) mediante dialisancia iónica (Kt<span class="elsevierStyleInf">DI</span>) en el paciente crítico y el grado de adecuación de la dosis en comparación con la medida estándar del Kt/V<span class="elsevierStyleInf">UREA</span>. <span class="elsevierStyleBold">Material y métodos: </span>Estudio prospectivo observacional de medida de dosis en 17 pacientes críticos con IRA sometidos a 3 sesiones de diálisis intermitente con prescripción predefinida para este estudio (en total 51 medidas). <span class="elsevierStyleBold">Resultados: </span>El Kt/V<span class="elsevierStyleInf">UREA</span> medio suministrado por sesión fue de 1,19 ± 0,14, con un 59% de sesiones consideradas adecuadas por lo recomendado por la ADQI. Por el contrario, la media de Kt<span class="elsevierStyleInf">DI</span> obtenida fue de 37,6 ± 1 l, con sólo un 29,4% igual o por encima del valor mínimo recomendado. <span class="elsevierStyleBold">Conclusiones: </span>La monitorización de la dosis mediante Kt<span class="elsevierStyleInf">DI</span> revela un menor grado de adecuación en comparación con el Kt/V<span class="elsevierStyleInf">UREA</span>. El carácter dinámico de la medida de Kt<span class="elsevierStyleInf">DI</span> puede permitir la adaptación de cada sesión de diálisis («K» y/o «t») con el fin de lograr el objetivo de dosis mínima.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10336108_a14_t1.jpg" "Alto" => 369 "Ancho" => 535 "Tamanyo" => 36883 ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the included patients and haemodialysis sessions." ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10336108_a14_f1.jpg" "Alto" => 480 "Ancho" => 528 "Tamanyo" => 22314 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lameire N, Van BW, Vanholder R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 6 | 13 |
| 2024 October | 48 | 38 | 86 |
| 2024 September | 63 | 33 | 96 |
| 2024 August | 63 | 55 | 118 |
| 2024 July | 58 | 34 | 92 |
| 2024 June | 80 | 38 | 118 |
| 2024 May | 77 | 30 | 107 |
| 2024 April | 73 | 32 | 105 |
| 2024 March | 39 | 24 | 63 |
| 2024 February | 45 | 35 | 80 |
| 2024 January | 45 | 16 | 61 |
| 2023 December | 41 | 30 | 71 |
| 2023 November | 48 | 36 | 84 |
| 2023 October | 41 | 27 | 68 |
| 2023 September | 40 | 28 | 68 |
| 2023 August | 36 | 18 | 54 |
| 2023 July | 42 | 25 | 67 |
| 2023 June | 30 | 12 | 42 |
| 2023 May | 53 | 36 | 89 |
| 2023 April | 45 | 12 | 57 |
| 2023 March | 50 | 11 | 61 |
| 2023 February | 30 | 22 | 52 |
| 2023 January | 45 | 14 | 59 |
| 2022 December | 53 | 22 | 75 |
| 2022 November | 62 | 29 | 91 |
| 2022 October | 44 | 46 | 90 |
| 2022 September | 54 | 24 | 78 |
| 2022 August | 45 | 41 | 86 |
| 2022 July | 42 | 49 | 91 |
| 2022 June | 38 | 44 | 82 |
| 2022 May | 43 | 22 | 65 |
| 2022 April | 40 | 62 | 102 |
| 2022 March | 57 | 55 | 112 |
| 2022 February | 40 | 44 | 84 |
| 2022 January | 41 | 29 | 70 |
| 2021 December | 72 | 42 | 114 |
| 2021 November | 64 | 31 | 95 |
| 2021 October | 72 | 43 | 115 |
| 2021 September | 51 | 32 | 83 |
| 2021 August | 54 | 33 | 87 |
| 2021 July | 56 | 29 | 85 |
| 2021 June | 52 | 22 | 74 |
| 2021 May | 45 | 32 | 77 |
| 2021 April | 121 | 72 | 193 |
| 2021 March | 68 | 24 | 92 |
| 2021 February | 69 | 18 | 87 |
| 2021 January | 40 | 17 | 57 |
| 2020 December | 48 | 20 | 68 |
| 2020 November | 41 | 25 | 66 |
| 2020 October | 18 | 4 | 22 |
| 2020 September | 26 | 2 | 28 |
| 2020 August | 43 | 8 | 51 |
| 2020 July | 51 | 11 | 62 |
| 2020 June | 41 | 13 | 54 |
| 2020 May | 44 | 7 | 51 |
| 2020 April | 42 | 15 | 57 |
| 2020 March | 56 | 22 | 78 |
| 2020 February | 46 | 18 | 64 |
| 2020 January | 55 | 21 | 76 |
| 2019 December | 68 | 22 | 90 |
| 2019 November | 59 | 19 | 78 |
| 2019 October | 46 | 13 | 59 |
| 2019 September | 49 | 18 | 67 |
| 2019 August | 40 | 5 | 45 |
| 2019 July | 48 | 18 | 66 |
| 2019 June | 51 | 19 | 70 |
| 2019 May | 41 | 16 | 57 |
| 2019 April | 102 | 39 | 141 |
| 2019 March | 56 | 23 | 79 |
| 2019 February | 34 | 18 | 52 |
| 2019 January | 26 | 15 | 41 |
| 2018 December | 83 | 40 | 123 |
| 2018 November | 62 | 8 | 70 |
| 2018 October | 74 | 11 | 85 |
| 2018 September | 73 | 19 | 92 |
| 2018 August | 61 | 12 | 73 |
| 2018 July | 49 | 13 | 62 |
| 2018 June | 47 | 17 | 64 |
| 2018 May | 52 | 11 | 63 |
| 2018 April | 82 | 13 | 95 |
| 2018 March | 59 | 7 | 66 |
| 2018 February | 60 | 8 | 68 |
| 2018 January | 51 | 8 | 59 |
| 2017 December | 59 | 5 | 64 |
| 2017 November | 47 | 16 | 63 |
| 2017 October | 39 | 8 | 47 |
| 2017 September | 37 | 11 | 48 |
| 2017 August | 25 | 9 | 34 |
| 2017 July | 28 | 4 | 32 |
| 2017 June | 40 | 13 | 53 |
| 2017 May | 37 | 8 | 45 |
| 2017 April | 26 | 6 | 32 |
| 2017 March | 26 | 12 | 38 |
| 2017 February | 24 | 13 | 37 |
| 2017 January | 33 | 10 | 43 |
| 2016 December | 59 | 6 | 65 |
| 2016 November | 74 | 6 | 80 |
| 2016 October | 105 | 14 | 119 |
| 2016 September | 127 | 5 | 132 |
| 2016 August | 177 | 3 | 180 |
| 2016 July | 141 | 2 | 143 |
| 2016 June | 111 | 0 | 111 |
| 2016 May | 121 | 0 | 121 |
| 2016 April | 101 | 0 | 101 |
| 2016 March | 81 | 0 | 81 |
| 2016 February | 106 | 0 | 106 |
| 2016 January | 104 | 0 | 104 |
| 2015 December | 99 | 0 | 99 |
| 2015 November | 84 | 0 | 84 |
| 2015 October | 82 | 0 | 82 |
| 2015 September | 83 | 0 | 83 |
| 2015 August | 71 | 0 | 71 |
| 2015 July | 69 | 0 | 69 |
| 2015 June | 50 | 0 | 50 |
| 2015 May | 41 | 0 | 41 |
| 2015 April | 10 | 0 | 10 |
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