Familial chronic interstitial nephropathy with hyperuricaemia caused by the UMOD gene
Nefropatía intersticial crónica familiar con hiperuricemia causada por el gen UMOD
Nadia Ayasreh-Fierroa, Elisabet Ars-Criachb, Vanesa Lopes-Martínc, Yolanda Arce-Terrobad, Patricia Ruiz-del Pradob, José Ballarín-Castáne, Roser Torra-Balcellsa
a Enfermedades Renales Hereditarias. Servicio de Nefrología, Fundación Puigvert, Barcelona,
b Laboratorio de Biología Molecular, Fundación Puigvert, Barcelona,
c Servicio de Nefrología, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá (REDINREN), Alcalá de Henares, Madrid,
d Anatomía Patológica, Fundación Puigvert, Barcelona,
e Servicio de Nefrología, Fundación Puigvert, Barcelona,
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Servicio de Nefrología, Fundación Puigvert, Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Laboratorio de Biología Molecular, Fundación Puigvert, Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá (REDINREN), Alcalá de Henares, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Anatomía Patológica, Fundación Puigvert, Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Servicio de Nefrología, Fundación Puigvert, Barcelona, " "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nefropatía intersticial crónica familiar con hiperuricemia causada por el gen UMOD" ] ] "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" => "11960_16025_49241_en_t111960.jpg" "Alto" => 565 "Ancho" => 2162 "Tamanyo" => 267479 ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the affected families" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Advances in medical genetics in recent decades have allowed for improvements in the diagnosis of familial nephropathies with broad phenotypic variability that until now were referred to as non-specific nephropathies. Overall, these nephropathies can manifest as glomerular disease (active urine sediment with proteinuria and/or haematuria) or as interstitial nephropathy (hyperuricaemia with or without gout, inactive or barely active urine sediment, and often with symptoms of polyuria and polydipsia). However, high variability within families often makes the diagnosis difficult.</p><p class="elsevierStylePara">Since the discovery of the UMOD gene<span class="elsevierStyleSup">1</span> and the recent implementation of its molecular study in cases of familial nephropathy with interstitial clinical findings and an autosomal dominant inheritance pattern, the number of patients identified with mutations in this gene has increased considerably.</p><p class="elsevierStylePara">We describe the case of a family with a mutation of the UMOD gene that presents with great intra-familial phenotype variability in which genetic study has made early diagnosis of young family members possible. In addition, we review the literature on this entity and the cases described in the literature to date.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CLINICAL CASE</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The index case is a male who began being seen in our centre at the age of 19 years due to a six-month history of general malaise and fatigue with alterations in renal function (creatinine 1.8mg/dl). He had a five-year history of hyperuricaemia with no episodes of gout that was controlled with allopurinol (100mg/day). Ultrasound of the kidneys and bladder revealed a decrease in the size of both kidneys (9-10cm) and there was no proteinuria or haematuria in the urine sediment. A renal biopsy (Figure 1) revealed non-specific changes: 4 glomeruli were normal and 3 were sclerotic, the tubules had an atrophic appearance and there was a lymphomononuclear infiltrate. The vessels were not affected and immunofluorescence was negative.</p><p class="elsevierStylePara">The patient had slowly-progressing renal failure and at 39 years of age he underwent a live-donor kidney transplant (his wife) without incident. The patient is currently 42 years, has very stable renal function with baseline creatinine levels of 1.5mg/dl-1.7mg/dl and is treated with allopurinol 100mg/day.</p><p class="elsevierStylePara">The family history indicates that various members of the family have renal involvement with hyperuricaemia with different levels of renal failures and polyuria with polydipsia (Figure 2) (Table 1). One brother (III-2), with chronic kidney disease and hyperuricaemia, underwent a transplant at 47 years. Another sister (III-1), also with chronic kidney disease and hyperuricaemia (at 35 years of age she has a creatinine level of 1.8mg/dl). The mother (II-4) of the three siblings also has chronic kidney disease, started dialysis at 34 years of age and died at 66 years of age.</p><p class="elsevierStylePara">The diagnosis of familial juvenile hyperuricaemic nephropathy was made by mutational analysis of the UMOD gene using direct sequencing of the 10 coding exons (exon 2-exon 11) from the genomic DNA of the index case. Mutational analysis allowed for the identification of the c.606G>C (pW202C) sequence variant in heterozygosis (Figure 3). This variant is located in exon 3 of the UMOD gene and has not been described previously in the literature, though another mutation that alters the same amino acid has been described [c.605G>C (p.W202S)<span class="elsevierStyleSup">2</span>]. The c/606G>C variant (p.W202C) was not identified in more than 200 control chromosomes analysed and it alters the tryptophan 202 amino acid that is conserved in orthologous proteins. In addition, the segregation of this familial variant was studied and it was found to be shared by all of the affected members. Different variant effect predictors (Condel, Sift, Polyphen) predicted that this is a pathogenic mutation. Because of the above, we concluded that the c.606G>C (p.W202C) variant was very likely the causal pathogenic mutation for the disease.</p><p class="elsevierStylePara">The diagnosis of this pathogenic mutation allowed for pre-symptomatic study of some of the young family members, as is the case in individuals IV:1 (affected) and IV:2 (not affected).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Uromodulin (UMOD), or Tamm-Horsfall protein (640 amino acids, molecular weight 85-90kDa)<span class="elsevierStyleSup">1</span> expressed in the ascending loop of Henle is the most abundant protein in urine under normal conditions. Although its function has not been completely defined, it has been associated with the impermeabilisation of the distal tubule, a protective effect against urinary tract infections and renal lithiasis, as well as pro-inflammatory activity.<span class="elsevierStyleSup">3,4</span> Dysfunction in this protein has been associated with the inability to concentrate urine and tubulointerstitial fibrosis.<span class="elsevierStyleSup">3</span> Patients with a mutation of the UMOD gene have a decrease in the levels of this protein in the urine due to abnormal folding that leads to accumulation in tubular epithelial cells.<span class="elsevierStyleSup">5</span> Although the pathologies caused by mutation of the UMOD gene are not generally included in the classification of ciliopathies,<span class="elsevierStyleSup">6</span> some studies have been published in the literature that do demonstrate UMOD expression in the primary cilia.<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Mutations of the UMOD gene (chromosome region 16p2)<span class="elsevierStyleSup">8,9</span> are responsible for two tubulointerstitial nephropathies with an autosomal dominant inheritance pattern, type 2 medullary cystic disease (MCKD2) [OMIM 603860] and familial juvenile hyperuricaemia (OMIM 162000], which is currently encompassed by the term “kidney disease caused by UMOD gene mutation”.<span class="elsevierStyleSup">5,10-14 A gene located at locus 1q21 MCKD1 [OMIM 174000], but not identified until now,15-18</span> is also responsible for tubulointerstitial nephropathy with an autosomal dominant inheritance pattern. It has a similar phenotype but an earlier presentation.</p><p class="elsevierStylePara">Kidney disease caused by a mutation in the UMOD gene has a very low prevalence, less than 1% of end-stage kidney disease (ESKD) in adults, though it may be underdiagnosed.<span class="elsevierStyleSup">5</span> In our case series of familial nephropathies with clinical signs of hyperuricaemic interstitial nephropathy, a mutation has been detected in the UMOD gene in 12.5% of cases (unpublished data), similar to those published in the literature.<span class="elsevierStyleSup">19</span></p><p class="elsevierStylePara">Uromodulin deficiency causes a deficit in tubular reabsorption, favouring polyuria and hyperuricaemia.<span class="elsevierStyleSup">13</span> The fraction of excreted uric acid appears decreased early in life (even in young patients with still-normal renal function) and usually is less than 5% in adult men and less than 6% in adult women.<span class="elsevierStyleSup">20</span> Uric acid levels above the 75<span class="elsevierStyleSup">th</span> percentile have been observed in more than 70% of these patients. Approximately 75% of men and 50% of women experience gout,<span class="elsevierStyleSup">19</span> but cases have also been described in which blood uric acid levels remain normal, especially in women.<span class="elsevierStyleSup">21</span> The disproportion between hyperuricaemia and the degree of renal failure is notable.<span class="elsevierStyleSup">19</span> All members of the family that were seen had hyperuricaemia since childhood and did not have a history of gout crisis.</p><p class="elsevierStylePara">The renal failure is slowly progressive, generally reaching the end stage between the fourth and sixth decades of life.<span class="elsevierStyleSup">19</span> The urine sediment is non-productive (proteinuria of less than 1g/day may appear in ESRD stages) and the kidney ultrasound usually reveals kidneys of reduced size and on some occasions may include medullary cysts (this has been seen in a third of patients in some series<span class="elsevierStyleSup">19</span>). The levels of kidney disease and the age at presentation are highly variable, both within families and across families.<span class="elsevierStyleSup">13,19,22-24 In our case, all of the affected family members had hyperuricaemia and, with the exception of individual III:5, normal urine sediment. Individual III:5 had mild proteinuria of 1.1.5 mg/dl in some sediment samples. Although the majority of cases described in the literature progress without proteinuria, there are some cases of mild proteinuria.25</span> The high level of disease progression variability within families is notable. The age for ESRD varies from early forms (approximate age 40 years), as in the index case or in individuals I:2 and III:2, to delayed forms (approximate age 60 years), as in the case of individuals II:1 or II:4. Therefore, the diagnosis of these nephropathies may be difficult if there is a significant familial load. Familial cases that are linked to MCKD1 usually have a higher level of hyperuricaemia and more frequent and early episodes of gout, ultimately reaching end-stage renal failure earlier in life.<span class="elsevierStyleSup">16,26,27</span></p><p class="elsevierStylePara">On a histological level, chronic interstitial nephritis, tubular atrophy and interstitial fibrosis can be observed and often lymphocytic infiltrate. The primary lesion is thinning and progressive loss of the tubular basement membrane and the formation of cysts in the distal tubule and collector tubes. Immunohistochemical studies may reveal abnormal deposits of uromodulin in the tubular cells.<span class="elsevierStyleSup">11,28</span> In this case, the renal biopsy was only performed in 2 of the 9 cases. In the index case (individual III:4), it was performed at the time of diagnosis (20 years of age), 20 years before reaching ESKD, and non-specific changes were observed. An early renal biopsy was also performed in individual III:1 (at 29 years of age). It revealed small foci of tubular atrophy and microcystic ectasia in isolated tubules with normal electron microscopy.</p><p class="elsevierStylePara">The genetic study is based on sequencing the UMOD gene and detecting mutations (some 50 mutations have been described so far).<span class="elsevierStyleSup">3,14,19,27</span> Given that the majority of mutations are located on exons 3 and 4 of the gene, these are usually studied first in the index case, though mutations in other exons, such as exon 7, have also been described.<span class="elsevierStyleSup">19</span> No clear phenotype-genotype correlation has been found.<span class="elsevierStyleSup">13,19,29</span> 90% of mutations are of the amino acid switch type (missense) and 62% alter the cysteine residue, leading to changes in protein folding.<span class="elsevierStyleSup">30</span> In the case of an absence of a UMOD gene mutation, analysis of the link for the MCKD1 region can be done if samples are available from other affected and non-affected family members.<span class="elsevierStyleSup">8,17,23</span></p><p class="elsevierStylePara">The UMOD gene is regulated by several transcription factors, among them HNF1b, whose mutation is responsible for another hyperuricaemic disease that should be suspected in cases with a compatible clinical presentation and if the studies cited above are negative.<span class="elsevierStyleSup">7,31,32</span></p><p class="elsevierStylePara">The primary indications for genetic diagnosis are workup for a live donor, the possibility of offering safe reproductive options and a pre-symptomatic diagnosis. The mutation found in this case has not been described previously. This is a missense-type mutation in an amino acid that is highly conserved across species with correct family segregation. The finding of this mutation allowed for the pre-symptomatic diagnosis of individual IV:1 and the disease was ruled out in individual IV:2.</p><p class="elsevierStylePara">There is no specific treatment for this disease nor is there for the other inherited cystic kidney diseases.<span class="elsevierStyleSup">5</span> Treatment with uricosuric medications may be helpful in reducing the progression of kidney disease,<span class="elsevierStyleSup">33</span> though the results are highly variable. Treatment with renin-angiotensin inhibitors is recommended due to the renal protective effect, though there are no clinical trials that demonstrate any specific benefits for this disease. Currently, there are no studies on specific medications for the treatment of uromodulin-associated kidney disease.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSIONS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Kidney disease caused by mutation of the UMOD gene is not a very well known entity and, due to its high variability within and across families, it is certainly very underdiagnosed. This nephropathy should be suspected in cases of non-specific kidney disease with an autosomal dominant inheritance pattern, normal urine sediment and a kidney biopsy with predominantly interstitial fibrosis. We should also keep in mind that, as with all hereditary kidney diseases, patients with a classic phenotype tend to undergo genetic study. Therefore, the phenotypic spectrum of the disease may be much broader than has been described so far.</p><p class="elsevierStylePara">It is likely that advances in medical genetics may some day in the not so distant future identify the MCKD1 gene as well as other genes involved in familial interstitial nephropathy. Therefore, it is expected that understanding of the familial interstitial nephropathies will grow and result in the discovery of therapeutic targets that will someday facilitate the treatment of this entity.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/11960_16025_49241_en_t111960.jpg" class="elsevierStyleCrossRefs"><img src="11960_16025_49241_en_t111960.jpg" alt="Clinical characteristics of the affected families"></img></a></p><p class="elsevierStylePara">Table 1. Clinical characteristics of the affected families</p><p class="elsevierStylePara"><a href="grande/11960_16025_49242_en_f111960.jpg" class="elsevierStyleCrossRefs"><img src="11960_16025_49242_en_f111960.jpg" alt="Renal biopsy of the index case"></img></a></p><p class="elsevierStylePara">Figure 1. Renal biopsy of the index case</p><p class="elsevierStylePara"><a href="grande/11960_16025_49243_en_f211960.jpg" class="elsevierStyleCrossRefs"><img src="11960_16025_49243_en_f211960.jpg" alt="Family pedigree"></img></a></p><p class="elsevierStylePara">Figure 2. Family pedigree</p><p class="elsevierStylePara"><a href="grande/11960_16025_49244_en_f311960.jpg" class="elsevierStyleCrossRefs"><img src="11960_16025_49244_en_f311960.jpg" alt="Sequence fragment from exon 3 of the UMOD gene"></img></a></p><p class="elsevierStylePara">Figure 3. Sequence fragment from exon 3 of the UMOD gene</p>" "pdfFichero" => "P1-E557-S4294-A11960-EN.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440316" "palabras" => array:1 [ 0 => "UMOD" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440318" "palabras" => array:1 [ 0 => "Familial juvenile hyperuricaemic nephropathy" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440320" "palabras" => array:1 [ 0 => "Hereditary interstitial chronic kidney diseases" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec440322" "palabras" => array:1 [ 0 => "Uromodulin" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11960_16025_49241_en_t111960.jpg" "Alto" => 565 "Ancho" => 2162 "Tamanyo" => 267479 ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of the affected families" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11960_16025_49242_en_f111960.jpg" "Alto" => 789 "Ancho" => 2121 "Tamanyo" => 736244 ] ] "descripcion" => array:1 [ "en" => "Renal biopsy of the index case" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11960_16025_49243_en_f211960.jpg" "Alto" => 1076 "Ancho" => 2115 "Tamanyo" => 157919 ] ] "descripcion" => array:1 [ "en" => "Family pedigree" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11960_16025_49244_en_f311960.jpg" "Alto" => 813 "Ancho" => 2115 "Tamanyo" => 257929 ] ] "descripcion" => array:1 [ "en" => "Sequence fragment from exon 3 of the UMOD gene" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pennica D, Kohr WJ, Kuang WJ, Glaister D, Aggarwal BB, Chen EY, et al. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 6 | 15 |
| 2024 October | 89 | 60 | 149 |
| 2024 September | 76 | 28 | 104 |
| 2024 August | 103 | 75 | 178 |
| 2024 July | 96 | 37 | 133 |
| 2024 June | 71 | 44 | 115 |
| 2024 May | 85 | 40 | 125 |
| 2024 April | 62 | 46 | 108 |
| 2024 March | 39 | 28 | 67 |
| 2024 February | 48 | 31 | 79 |
| 2024 January | 49 | 25 | 74 |
| 2023 December | 50 | 45 | 95 |
| 2023 November | 90 | 40 | 130 |
| 2023 October | 65 | 26 | 91 |
| 2023 September | 89 | 31 | 120 |
| 2023 August | 68 | 31 | 99 |
| 2023 July | 67 | 27 | 94 |
| 2023 June | 60 | 23 | 83 |
| 2023 May | 87 | 33 | 120 |
| 2023 April | 65 | 20 | 85 |
| 2023 March | 71 | 28 | 99 |
| 2023 February | 59 | 24 | 83 |
| 2023 January | 75 | 36 | 111 |
| 2022 December | 100 | 47 | 147 |
| 2022 November | 68 | 38 | 106 |
| 2022 October | 85 | 50 | 135 |
| 2022 September | 57 | 40 | 97 |
| 2022 August | 94 | 47 | 141 |
| 2022 July | 82 | 54 | 136 |
| 2022 June | 89 | 38 | 127 |
| 2022 May | 96 | 34 | 130 |
| 2022 April | 153 | 55 | 208 |
| 2022 March | 111 | 38 | 149 |
| 2022 February | 86 | 35 | 121 |
| 2022 January | 104 | 35 | 139 |
| 2021 December | 108 | 42 | 150 |
| 2021 November | 68 | 37 | 105 |
| 2021 October | 66 | 37 | 103 |
| 2021 September | 42 | 32 | 74 |
| 2021 August | 76 | 38 | 114 |
| 2021 July | 64 | 44 | 108 |
| 2021 June | 50 | 20 | 70 |
| 2021 May | 63 | 27 | 90 |
| 2021 April | 125 | 53 | 178 |
| 2021 March | 115 | 37 | 152 |
| 2021 February | 115 | 36 | 151 |
| 2021 January | 64 | 27 | 91 |
| 2020 December | 46 | 14 | 60 |
| 2020 November | 59 | 19 | 78 |
| 2020 October | 61 | 12 | 73 |
| 2020 September | 42 | 17 | 59 |
| 2020 August | 47 | 6 | 53 |
| 2020 July | 58 | 15 | 73 |
| 2020 June | 50 | 19 | 69 |
| 2020 May | 56 | 18 | 74 |
| 2020 April | 52 | 14 | 66 |
| 2020 March | 42 | 13 | 55 |
| 2020 February | 51 | 18 | 69 |
| 2020 January | 65 | 19 | 84 |
| 2019 December | 78 | 34 | 112 |
| 2019 November | 52 | 21 | 73 |
| 2019 October | 51 | 10 | 61 |
| 2019 September | 62 | 23 | 85 |
| 2019 August | 53 | 14 | 67 |
| 2019 July | 60 | 25 | 85 |
| 2019 June | 46 | 18 | 64 |
| 2019 May | 53 | 23 | 76 |
| 2019 April | 92 | 34 | 126 |
| 2019 March | 43 | 22 | 65 |
| 2019 February | 40 | 13 | 53 |
| 2019 January | 40 | 23 | 63 |
| 2018 December | 116 | 38 | 154 |
| 2018 November | 93 | 17 | 110 |
| 2018 October | 71 | 10 | 81 |
| 2018 September | 82 | 11 | 93 |
| 2018 August | 53 | 17 | 70 |
| 2018 July | 46 | 19 | 65 |
| 2018 June | 50 | 6 | 56 |
| 2018 May | 56 | 14 | 70 |
| 2018 April | 58 | 12 | 70 |
| 2018 March | 57 | 14 | 71 |
| 2018 February | 46 | 10 | 56 |
| 2018 January | 73 | 12 | 85 |
| 2017 December | 54 | 19 | 73 |
| 2017 November | 62 | 12 | 74 |
| 2017 October | 45 | 12 | 57 |
| 2017 September | 51 | 14 | 65 |
| 2017 August | 49 | 11 | 60 |
| 2017 July | 48 | 12 | 60 |
| 2017 June | 58 | 4 | 62 |
| 2017 May | 72 | 17 | 89 |
| 2017 April | 65 | 16 | 81 |
| 2017 March | 36 | 18 | 54 |
| 2017 February | 47 | 6 | 53 |
| 2017 January | 51 | 16 | 67 |
| 2016 December | 73 | 7 | 80 |
| 2016 November | 73 | 18 | 91 |
| 2016 October | 131 | 15 | 146 |
| 2016 September | 115 | 3 | 118 |
| 2016 August | 184 | 6 | 190 |
| 2016 July | 192 | 13 | 205 |
| 2016 June | 148 | 0 | 148 |
| 2016 May | 135 | 0 | 135 |
| 2016 April | 132 | 0 | 132 |
| 2016 March | 118 | 0 | 118 |
| 2016 February | 115 | 0 | 115 |
| 2016 January | 137 | 0 | 137 |
| 2015 December | 144 | 0 | 144 |
| 2015 November | 100 | 0 | 100 |
| 2015 October | 104 | 0 | 104 |
| 2015 September | 86 | 0 | 86 |
| 2015 August | 83 | 0 | 83 |
| 2015 July | 85 | 0 | 85 |
| 2015 June | 58 | 0 | 58 |
| 2015 May | 76 | 0 | 76 |
| 2015 April | 5 | 0 | 5 |
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