Pleuroperitoneal communication in patients on peritoneal dialysis. One hospital's experience and a review of the literature
Comunicación pleuro-peritoneal en pacientes en diálisis peritoneal. Experiencia en un centro y revisión de la literatura
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One hospital's experience and a review of the literature" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "213" "paginaFinal" => "217" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "R. Díaz Mancebo, G. del Peso Gilsanz, M. Rodríguez, B. Fernández, M. Ossorio González, M.A. Bajo Rubio, R. Selgas Gutiérrez" "autores" => array:9 [ 0 => null 1 => array:4 [ "Iniciales" => "R." "apellidos" => "Díaz Mancebo" "email" => array:1 [ 0 => "rakadm@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:4 [ "Iniciales" => "R." "apellidos" => "Díaz Mancebo" "email" => array:1 [ 0 => "rdiazm.hulp@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "Iniciales" => "G." 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"apellidos" => "Selgas Gutiérrez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario La Paz, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comunicación pleuro-peritoneal en pacientes en diálisis peritoneal. Experiencia en un centro y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1a" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10762_16025_15292_en_10762f1.jpg" "Alto" => 628 "Ancho" => 600 "Tamanyo" => 196925 ] ] "descripcion" => array:1 [ "en" => "Peritoneal scintigram with Tc-99m nanocolloid tracer." ] ] ] "textoCompleto" => "<p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Peritoneal dialysis (PD) is a replacement therapy option for patients with advanced chronic kidney disease. During this procedure there is an increase in intra-abdominal pressure<span class="elsevierStyleSup">1,2</span> due to the accumulation of dialysate in the peritoneal cavity. Among the complications secondary to this increase in pressure is the leakage of peritoneal fluid through the diaphragm to the thorax, known as pleuroperitoneal communication<span class="elsevierStyleSup">3</span> or secondary hydrothorax, described in 1967 by Edward and Unger.<span class="elsevierStyleSup">4</span> The mean incidence has been estimated at between 1.6% and 10%,<span class="elsevierStyleSup">5,6</span> although it may be higher as hydrothorax involving small amounts of fluid are difficult to diagnose. Its aetiopathogenesis is not fully understood, but it has been related to congenital or acquired pleuroperitoneal defects<span class="elsevierStyleSup">7 </span>and to lymphatic drainage disorders.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The aim of this article is to analyse the incidence of this complication in our hospital setting and expound our experience in diagnosing and treating it.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORTS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">We have reviewed the medical records of all the patients treated with PD in our unit between 1997 and 2010. During this time, 328 patients began this therapy in the La Paz University Hospital in Madrid. Six were diagnosed with pleuroperitoneal communication. Here, we present the cases in chronological order, from the first to be diagnosed to the most recent. Table 1 shows a summary of the cases including the method of diagnosis and the initial treatment.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 1</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A 55 year old woman with chronic renal failure (CRF) secondary to reflux nephropathy who began renal replacement therapy with automated PD (APD) in 1983. She received a kidney transplant 4 years later from a cadaveric donor, developing chronic graft nephropathy requiring renal replacement therapy 11 years later. She began APD again and 7 months later presented symptoms of<span class="elsevierStyleBold"> </span>dyspnoea with a significant volume overload and a loss of ultrafiltration in the preceding days. A chest x-ray showed mainly right-sided bilateral pleural effusion. In view of suspected pleuroperitoneal communication a peritoneal scintigraphy was performed which confirmed the diagnosis. Given the severity of her condition, the patient was transferred to haemodialysis (HD) on a definitive basis.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 2</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A 60 year old man with CRF of unknown origin under treatment with APD since 2000. A month after beginning treatment he presented symptoms of<span class="elsevierStyleBold"> </span>progressive dyspnoea, loss of ultrafiltration and volume overload. A chest x-ray was performed showing massive right-sided pleural effusion. A thoracentesis was performed, the analysis of the pleural fluid showed a glucose concentration higher than the plasma concentration, suggesting possible pleuroperitoneal communication. Peritoneal scintigraphy with <span class="elsevierStyleSup">99</span>Tc-labelled albumin was carried out, confirming the diagnosis of pleuroperitoneal communication. The patient was transferred to HD for 3 months, and then he began APD again. After 5 months' treatment with APD there was evidence of a relapse of the pleuroperitoneal communication, so talc pleurodesis was carried out. After 2 months on HD the patient started PD again and had no other related complications in the following 3 years.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 3</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A 52 year old man with CRF secondary to membranoproliferative glomerulonephritis (GN) under treatment with continuous ambulatory PD (CAPD) since February 2001. Two months after beginning treatment he presented acute respiratory failure with volume overload. He underwent a chest x-ray, thoracentesis and peritoneal scintigraphy, resulting in a diagnosis of pleuroperitoneal communication. Talc pleurodesis was performed with peritoneal rest for 2 months. A month after beginning CAPD again, he suffered a relapse of pleuroperitoneal communication, so pleurodesis was performed again. He began CAPD again 3 months later, continuing the treatment for 6 months until receiving a kidney transplant. The patient suffered no new complications during that period.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 4</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A 74 year old man with CRF secondary to nephroangiosclerosis under treatment with CAPD since September 1998. In October 2001, after 2 years of treatment, he began to suffer symptoms of dyspnoea and a chest x-ray showed bilateral pleural effusion. Peritoneal scintigraphy provided confirmation of the diagnosis with tracer uptake in the base of the left hemithorax. He was transferred to HD and after 4 months peritoneal scintigraphy was performed showing that a small amount of tracer still entered both hemithoraxes. PD was begun again as it was requested by the patient. After 6 months he was transferred to definitive HD due to <span class="elsevierStyleItalic">Candida albicans </span>peritonitis, before which there had been no evidence of a relapse.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 5</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A 51 year old man with CRF secondary to chronic pyelonephritis due to a neurogenic bladder and vesicoureteral reflux. After 10 years' treatment with HD he was transferred to APD in June 2006 because of vascular access problems. After 9 months' treatment with DP he began to suffer from progressive dyspnoea and a CT scan of the abdomen and thorax confirmed moderate right-sided pleural effusion. A diagnostic thoracentesis was performed revealing higher levels of glucose in relation to plasma in the peritoneal fluid. The diagnosis of pleuroperitoneal communication was confirmed with peritoneal scintigraphy with <span class="elsevierStyleSup">99</span>Tc-labelled albumin. Talc pleurodesis was performed and the patient was transferred temporarily to HD. After 2 months' peritoneal rest he began APD again with a dry day. Six months later, after beginning continuous cyclic peritoneal dialysis (CCPD), he presented symptoms of dyspnoea and a chest x-ray revealed right-sided pleural effusion, probably related to a relapse of the prior pleuroperitoneal communication, so he was transferred to HD for 6 months. At present he is under APD treatment with a dry day, with no new complications after 2 years' follow-up.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case 6</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A 47 year old woman with CRF secondary to nephroangiosclerosis under treatment with CCPD since June 2009. After 5 months of treatment, she presented symptoms of dyspnoea with minimal effort and was unable to tolerate the decubitus position. A chest x-ray was carried out showing massive right-sided pleural effusion. The diagnosis was confirmed using peritoneal scintigraphy, which showed the flow of peritoneal fluid from the abdominal cavity to the right lung field. Talc pleurodesis was performed and the patient transferred to HD for 2 months. Then, she returned to DP without relapse of the pleuroperitoneal communication after 10 months on this treatment.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Pleuroperitoneal communication is a rare complication in patients on DP, but it results in a high drop-out rate. In our series we observed an incidence of 1.84%, which is a slightly lower percentage than in other series in the literature.<span class="elsevierStyleSup">5,6</span> Although most of the cases traditionally described have been women, only one patient in our series was female, with the added peculiarity that she had been treated with DP for 4 years in a previous stage without any complications. The cause of the CRF has also been associated with this complication, it being more common in patients with hepatorenal polycystic disease<span class="elsevierStyleSup">9</span> due to an added increase in intra-abdominal pressure. In our series there were no patients with polycystic kidney disease. With regard to the location, 2 of our patients suffered from bilateral pleuroperitoneal communication, which is uncommon according to the medical literature, where a higher prevalence of right-sided only hydrothorax is reported.<span class="elsevierStyleSup">10</span> It has been suggested that this could be related to a malformation in this location.<span class="elsevierStyleSup">1,6,11</span> Gagnon and Daniels proposed the existence of embryonic remnant, the persisting pneumatoenteric recess, which allows fluids to pass from the peritoneal cavity to the right pleural space.<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Diagnosing this problem is simple but clinical suspicion is crucial. It is necessary to rule out pleuroperitoneal communication when faced with a patient treated with DP presenting with dyspnoea of more or less sudden onset, loss of ultrafiltration and pleural effusion.<span class="elsevierStyleSup">7</span> If a pleural fluid sample obtained from a thoracentesis shows that the glucose concentration is higher than that of the plasma, positive diagnosis can be suspected.<span class="elsevierStyleSup">12,13</span> Peritoneal scintigraphy has been shown to be very effective at confirming the diagnosis of this anatomic disorder.<span class="elsevierStyleSup">14,15</span> It shows how the radioactive isotope passes from the peritoneal cavity through the pleura to the thorax. Figure 1 shows the different images corresponding to a peritoneal scintigram of a patient with this complication.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">There are several treatment options: the conservative option, pleurodesis or surgery. None of these has been shown to be better than the others so the decision depends on the patient's clinical condition and their preference. Patients should be previously informed of the risks and benefits of the different options.<span class="elsevierStyleSup">16</span> Pleuroperitoneal communication is a clinical situation with little relevance outside the context of PD, thus, conservative treatment may be the most suitable option for patients who will be transferred to haemodialysis. In our series, one of the patients has not had a relapse since beginning HD.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Once the diagnosis has been confirmed, the most important step to take is the temporary, or even permanent, interruption of PD, which is determined by the magnitude of the communication and the needs of the individual patient. Conservative treatment has been seen to be effective in approximately 50% of patients,<span class="elsevierStyleSup">5</span> however, our attempt to treat one patient with peritoneal rest was unsuccessful. In some patients with preserved residual diuresis low-volume CAPD could be continued<span class="elsevierStyleSup">17,18</span> or low volume APD and a dry day.<span class="elsevierStyleSup">19,20 </span>However, this option could lead to under-dialysis and is not viable with anuric patients. In our hospital, patients were treated with peritoneal rest with a temporary transfer to HD,<span class="elsevierStyleSup">21</span> which is an essential decision, particularly if the pleural effusion results in breathing conditions. Talc pleurodesis is a safe and effective treatment for pleuroperitoneal communication.<span class="elsevierStyleSup">22</span> In our series, it was performed on 3 patients, 2 at onset and one after a relapse. With one patient it was necessary to carry out the procedure twice, but there were no complications during the procedure in any of the cases. These patients wanted to continue on PD and pleurodesis was chosen for this reason. PD was never maintained because there was a contraindication for a definitive transfer to HD, as would be the case if there were no vascular access. There are other treatment options such as tetracycline pleurodesis, which provides similar results to talc pleurodesis,<span class="elsevierStyleSup">23</span> or pleurodesis with autologous blood, which has had inconsistent results.<span class="elsevierStyleSup">24-26</span> </p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Video-assisted thoracoscopic surgery allows for the direct visualisation of the diaphragm and malformations in this area.<span class="elsevierStyleSup">27</span> If the condition is associated with a morphological disorder, a thoracotomy and direct repair is mandatory. Although it is an aggressive treatment, it offers a high rate of success. However, although surgery is very effective,<span class="elsevierStyleSup">28</span> it is reserved as the last treatment option as it is not devoid of risks.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">In general, with both conservative or surgical treatment, up to 58% of patients can continue on PD treatment.<span class="elsevierStyleSup">21</span> However, the relapse rate is generally high, which is why the results with the different treatments are not very encouraging<span class="elsevierStyleSup">6,29</span> and a high percentage of cases require a definitive transfer to HD<span class="elsevierStyleSup">30</span>. This means that it is not possible to give clear directions in favour of one treatment or the other.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara">Pleuroperitoneal communication is a rare complication in patients on PD, but it leads to a high drop-out rate from the treatment. Its diagnosis is easy and its clinical suspicion is extremely important. The treatment involves peritoneal rest accompanied or not by pleurodesis.</p><p class="elsevierStylePara"><a href="grande/10762_16025_15292_en_10762f1.jpg" class="elsevierStyleCrossRefs"><img src="10762_16025_15292_en_10762f1.jpg" alt="Peritoneal scintigram with Tc-99m nanocolloid tracer."></img></a></p><p class="elsevierStylePara">Figure 1a. Peritoneal scintigram with Tc-99m nanocolloid tracer.</p><p class="elsevierStylePara"><a href="grande/10762_16025_15293_en_10762f2.jpg" class="elsevierStyleCrossRefs"><img src="10762_16025_15293_en_10762f2.jpg" alt="Peritoneal scintigram with Tc-99m nanocolloid tracer"></img></a></p><p class="elsevierStylePara">Figure 1b. Peritoneal scintigram with Tc-99m nanocolloid tracer</p><p class="elsevierStylePara"><a href="grande/10762_16025_15294_en_10762f3.jpg" class="elsevierStyleCrossRefs"><img src="10762_16025_15294_en_10762f3.jpg" alt="Peritoneal scintigram with Tc-99m nanocolloid tracer"></img></a></p><p class="elsevierStylePara">Figure 1c. Peritoneal scintigram with Tc-99m nanocolloid tracer</p><p class="elsevierStylePara"><a href="grande/10762_16025_15295_en_t1.jpg" class="elsevierStyleCrossRefs"><img src="10762_16025_15295_en_t1.jpg" alt="Description of the series"></img></a></p><p class="elsevierStylePara">Table 1. Description of the series</p>" "tienePdf" => false "PalabrasClave" => array:2 [ "es" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec441321" "palabras" => array:1 [ 0 => "hidrotórax secundario" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec441323" "palabras" => array:1 [ 0 => "Comunicación pleuro-peritoneal" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec441325" "palabras" => array:1 [ 0 => "Diálisis peritoneal" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec441327" "palabras" => array:1 [ 0 => "Pleurodesis" ] ] ] "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441322" "palabras" => array:1 [ 0 => "Secondary hydrothorax" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441324" "palabras" => array:1 [ 0 => "Pleuroperitonal communication" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441326" "palabras" => array:1 [ 0 => "Peritoneal dialysis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec441328" "palabras" => array:1 [ 0 => "Pleurodesis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "<p class="elsevierStylePara">Peritoneal dialysis is a treatment alternative in patients with advanced chronic kidney disease. The infusion of liquid into the peritoneal cavity leads to an increase in intra-abdominal pressure, which can sometimes produce leaks to the chest, giving rise to pleuroperitoneal communication. This is not a common complication, but it brings about high drop-out rates among patients using the technique. Diagnosis is easy and must be suspected in patients with sudden dyspnoea with low ultrafiltration and pleural effusion in the chest x-ray. Peritoneal rest and a temporary transfer to haemodialysis, and pleurodesis can be effective treatment strategies.</p>" ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"> </p> <p class="elsevierStylePara">La diálisis peritoneal es una alternativa de tratamiento en los pacientes con enfermedad renal crónica avanzada. La infusión de líquido en la cavidad peritoneal conlleva un aumento de presión intraabdominal que, en algunas ocasiones, puede producir la fuga del mismo hacia el tórax dando lugar a una comunicación pleuro-peritoneal. Es una complicación poco frecuente, pero supone una alta tasa de abandono de la técnica. El diagnóstico es sencillo y se debe sospechar ante la existencia de disnea súbita con baja ultrafiltración y derrame pleural en la radiografía de tórax. El descanso peritoneal, con transferencia temporal a hemodiálisis, y la pleurodesis pueden ser estrategias eficaces para su tratamiento.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1a" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10762_16025_15292_en_10762f1.jpg" "Alto" => 628 "Ancho" => 600 "Tamanyo" => 196925 ] ] "descripcion" => array:1 [ "en" => "Peritoneal scintigram with Tc-99m nanocolloid tracer." ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 1b" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10762_16025_15293_en_10762f2.jpg" "Alto" => 651 "Ancho" => 600 "Tamanyo" => 217496 ] ] "descripcion" => array:1 [ "en" => "Peritoneal scintigram with Tc-99m nanocolloid tracer" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 1c" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10762_16025_15294_en_10762f3.jpg" "Alto" => 639 "Ancho" => 600 "Tamanyo" => 210511 ] ] "descripcion" => array:1 [ "en" => "Peritoneal scintigram with Tc-99m nanocolloid tracer" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10762_16025_15295_en_t1.jpg" "Alto" => 193 "Ancho" => 600 "Tamanyo" => 104889 ] ] "descripcion" => array:1 [ "en" => "Description of the series" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mahale AS,\u{A0}Katyal A,\u{A0}Khanna R. 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Nefrologia 2010;30(5):594-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20882101" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 29 => array:3 [ "identificador" => "bib30" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "García Ramón R, Miguel Carrasco A. Hydrothorax in peritoneal dialysis. Perit Dial Int 1998;18:540-5." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003100000002/v0_201502091641/X2013251411051610/v0_201502091641/en/main.assets" "Apartado" => array:4 [ "identificador" => "35441" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411051610?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 0 | 11 |
| 2024 October | 88 | 0 | 88 |
| 2024 September | 92 | 0 | 92 |
| 2024 August | 110 | 0 | 110 |
| 2024 July | 65 | 0 | 65 |
| 2024 June | 125 | 0 | 125 |
| 2024 May | 94 | 0 | 94 |
| 2024 April | 72 | 0 | 72 |
| 2024 March | 74 | 4 | 78 |
| 2024 February | 48 | 14 | 62 |
| 2024 January | 59 | 6 | 65 |
| 2023 December | 59 | 10 | 69 |
| 2023 November | 95 | 7 | 102 |
| 2023 October | 76 | 12 | 88 |
| 2023 September | 93 | 13 | 106 |
| 2023 August | 82 | 4 | 86 |
| 2023 July | 114 | 4 | 118 |
| 2023 June | 75 | 7 | 82 |
| 2023 May | 73 | 10 | 83 |
| 2023 April | 65 | 4 | 69 |
| 2023 March | 80 | 12 | 92 |
| 2023 February | 55 | 14 | 69 |
| 2023 January | 74 | 11 | 85 |
| 2022 December | 69 | 17 | 86 |
| 2022 November | 62 | 15 | 77 |
| 2022 October | 87 | 18 | 105 |
| 2022 September | 87 | 2481 | 2568 |
| 2022 August | 93 | 20 | 113 |
| 2022 July | 86 | 17 | 103 |
| 2022 June | 90 | 12 | 102 |
| 2022 May | 107 | 17 | 124 |
| 2022 April | 124 | 14 | 138 |
| 2022 March | 113 | 17 | 130 |
| 2022 February | 111 | 15 | 126 |
| 2022 January | 92 | 19 | 111 |
| 2021 December | 117 | 17 | 134 |
| 2021 November | 82 | 12 | 94 |
| 2021 October | 77 | 17 | 94 |
| 2021 September | 74 | 20 | 94 |
| 2021 August | 109 | 14 | 123 |
| 2021 July | 55 | 13 | 68 |
| 2021 June | 79 | 8 | 87 |
| 2021 May | 73 | 84 | 157 |
| 2021 April | 130 | 22 | 152 |
| 2021 March | 105 | 22 | 127 |
| 2021 February | 125 | 12 | 137 |
| 2021 January | 66 | 12 | 78 |
| 2020 December | 76 | 7 | 83 |
| 2020 November | 96 | 13 | 109 |
| 2020 October | 63 | 12 | 75 |
| 2020 September | 63 | 4 | 67 |
| 2020 August | 58 | 7 | 65 |
| 2020 July | 79 | 5 | 84 |
| 2020 June | 155 | 11 | 166 |
| 2020 May | 69 | 10 | 79 |
| 2020 April | 62 | 16 | 78 |
| 2020 March | 82 | 10 | 92 |
| 2020 February | 58 | 15 | 73 |
| 2020 January | 79 | 12 | 91 |
| 2019 December | 117 | 22 | 139 |
| 2019 November | 67 | 8 | 75 |
| 2019 October | 48 | 3 | 51 |
| 2019 September | 65 | 10 | 75 |
| 2019 August | 40 | 7 | 47 |
| 2019 July | 57 | 17 | 74 |
| 2019 June | 37 | 2 | 39 |
| 2019 May | 46 | 3 | 49 |
| 2019 April | 97 | 6 | 103 |
| 2019 March | 31 | 13 | 44 |
| 2019 February | 34 | 7 | 41 |
| 2019 January | 51 | 8 | 59 |
| 2018 December | 62 | 31 | 93 |
| 2018 November | 151 | 15 | 166 |
| 2018 October | 102 | 27 | 129 |
| 2018 September | 59 | 12 | 71 |
| 2018 August | 63 | 7 | 70 |
| 2018 July | 44 | 30 | 74 |
| 2018 June | 39 | 11 | 50 |
| 2018 May | 53 | 11 | 64 |
| 2018 April | 38 | 9 | 47 |
| 2018 March | 53 | 14 | 67 |
| 2018 February | 47 | 26 | 73 |
| 2018 January | 44 | 9 | 53 |
| 2017 December | 44 | 8 | 52 |
| 2017 November | 69 | 10 | 79 |
| 2017 October | 48 | 8 | 56 |
| 2017 September | 53 | 39 | 92 |
| 2017 August | 39 | 14 | 53 |
| 2017 July | 49 | 12 | 61 |
| 2017 June | 51 | 10 | 61 |
| 2017 May | 64 | 8 | 72 |
| 2017 April | 50 | 27 | 77 |
| 2017 March | 41 | 3 | 44 |
| 2017 February | 33 | 27 | 60 |
| 2017 January | 27 | 6 | 33 |
| 2016 December | 99 | 4 | 103 |
| 2016 November | 89 | 5 | 94 |
| 2016 October | 119 | 27 | 146 |
| 2016 September | 154 | 11 | 165 |
| 2016 August | 212 | 0 | 212 |
| 2016 July | 203 | 0 | 203 |
| 2016 June | 158 | 0 | 158 |
| 2016 May | 122 | 0 | 122 |
| 2016 April | 81 | 0 | 81 |
| 2016 March | 66 | 0 | 66 |
| 2016 February | 131 | 0 | 131 |
| 2016 January | 119 | 0 | 119 |
| 2015 December | 110 | 0 | 110 |
| 2015 November | 74 | 0 | 74 |
| 2015 October | 68 | 0 | 68 |
| 2015 September | 67 | 0 | 67 |
| 2015 August | 52 | 0 | 52 |
| 2015 July | 70 | 0 | 70 |
| 2015 June | 34 | 0 | 34 |
| 2015 May | 93 | 0 | 93 |
| 2015 April | 9 | 0 | 9 |
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