Letter to the Editor
When kidneys are no longer a friend: An “out of the box” management for an unexpected evolution of an uncommon disease
Cuando los riñones dejan de ser un amigo: Una gestión “fuera de la caja” de una evolución imprevista de una enfermedad poco común
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A) Genu-varo marcado en miembro inferior izquierdo con edema leve. B) Rx AP de rodilla izquierda, fractura incompleta zona de epífisis distal de fémur izquierdo, con imagen radiopaca infiltrante. C) TC en misma zona anatómica, lesión sólida osteolítica de 40<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>33<span class="elsevierStyleHsp" style=""></span>mm en la epífisis distal del fémur, el cartílago de crecimiento impresiona respetado. D) Muestra histológica procesada, se denota gran cantidad de células multinucleadas. E) RMN en misma zona anatómica, proceso ocupativo heterogéneo irregular metafisario con compromiso de porción ósea y de la cortical con epicentro en la porción metafisaria femoral distal de 35<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>33<span class="elsevierStyleHsp" style=""></span>mm y con la presencia de líquido perilesional, no compromete otras estructuras. F) Estudio de gammagrafía con rastreo corporal total con <span class="elsevierStyleSup">99m</span>Tc-sestaMIBI muestra captación de radiofármaco en metáfisis distal de fémur izquierdo. G) Visión tomográfica en 3 dimensiones, vista lateral y posterior de epífisis distal de fémur izquierdo. H) Identificación precisa de la célula gigante multinucleada, característica del tumor pardo óseo.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Fuente: Elaborado por Juan Miguel Alemán I; Tomado del Centro de Imágenes del Hospital José Carrasco Arteaga y Centro de Patología del Hospital José Carrasco Arteaga.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan Miguel Alemán-Iñiguez, Franklin Mora-Bravo, Christian Bravo-Aguilar" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Juan Miguel" "apellidos" => "Alemán-Iñiguez" ] 1 => array:2 [ "nombre" => "Franklin" "apellidos" => "Mora-Bravo" ] 2 => array:2 [ "nombre" => "Christian" "apellidos" => "Bravo-Aguilar" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S201325141630102X" "doi" => "10.1016/j.nefroe.2016.11.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S201325141630102X?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699516300200?idApp=UINPBA000064" "url" => "/02116995/0000003600000005/v3_201705130058/S0211699516300200/v3_201705130058/es/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "When kidneys are no longer a friend: An “out of the box” management for an unexpected evolution of an uncommon disease" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor</span>," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "563" "paginaFinal" => "565" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sandra Silva, Ricardo Pereira, Ivo Cunha, Carlos Ferreira, Ana Branco, Eduardo Eiras, Mrinalini Honavar, Joana 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"apellidos" => "Chuva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 10 => array:3 [ "nombre" => "José" "apellidos" => "Costa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Nephrology, Hospital Pedro Hispano, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Internal Medicine, Hospital Pedro Hispano, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Urology, Hospital Pedro Hispano, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Pathology, Hospital Pedro Hispano, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuando los riñones dejan de ser un amigo: Una gestión “fuera de la caja” de una evolución imprevista de una enfermedad poco común" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 626 "Ancho" => 1700 "Tamanyo" => 228234 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histological examination of the kidneys. (A) Glomerular nodular deposits of amyloid stained with Congo red. (B) Amyloid showing typical apple-green birefringence under polarized light.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">AA amyloidosis (AAA) is one of most severe complications of chronic inflammatory and infectious diseases and may induce nephrotic syndrome.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Its association with Crohn's disease has been regularly reported, but amyloidosis complicating ulcerative colitis (UC) has been described only exceptionally.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of a 58-year-old woman who was admitted with anasarca and nephrotic syndrome (NS). Relevant medical history included UC, gangrenous pyoderma and a tuberculous empyema. In 2002, a NS was identified and a renal biopsy displayed the diagnosis of AAA. In addition to treatment with 5-aminosalicylic-acid, a trial of colchicine was implemented but had to be stopped due to diarrhea. Renal function (RF) was sustainably preserved and the proteinuria spontaneously remitted. Throughout time she had long-lasting, moderate gastrointestinal symptoms with evidence of mild endoscopic inflammation. In 2015 she developed once more disabling proteinuria with normal RF and a diagnostic workup corroborated the clinical impression of recurrence of her amyloidosis (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). An endoscopic review exhibited mild disease and, in addition to messalazine and prednisone, she was started on azathioprine, which had to be suspended due to pancreatitis. Therapy with an angiotensin-converting enzyme inhibitor was initiated but not tolerated; albumin-plus-furosemide infusion led merely to temporary improvement. A decision to deteriorate RF to decrease proteinuria was attempted: indomethacin led to acute renal dysfunction but didn’t significantly improved proteinuria. Hemodialysis was started but had to be interrupted due to hemodynamic instability. After a multidisciplinary consultation, she underwent a bilateral nephrectomy. Post-operatively, serum albumin and postural symptoms gradually improved with subsequent better hemodialysis tolerance. Histology revealed extensive amyloid deposits (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and immunohistochemical staining was positive for AA amyloid. Nutritional and functional status gradually improved.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">AAA in the setting of UC is a rarity and typically, severe gastrointestinal illness precedes the development of amyloidosis,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> however this was not the case in our patient, who had a long standing, though mild disease. We speculate that the ongoing activity and the prolonged duration may have had a role; nevertheless, an additional contribution from the tuberculosis cannot be ruled out.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Another peculiar aspect is the spontaneous remission of the patient's NS. Improvement of amyloidosis manifestations is extensively documented in the context of remission of the underlying disease, but spontaneous regression is extremely unlikely.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with large proteinuria due to AAA can experience a life-threatening cachexic state with massive edema, respiratory distress and infectious complications, along with a poor functional status and a reduced quality-of-life. Up to the present, AAA has no specific treatment and despite the development of novel therapies (eprodisate)<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> targeting the formation/stability of fibrils, the current available approach is to treat the underlying condition and thereby reduce the amyloid production. Nevertheless, this goal is not always achieved and the management of proteinuria can be challenging, resorting, in intractable cases like ours, to renal ablation. Medical ablation, with non-steroidal anti-inflammatory drugs<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> has been attempted; bilateral renal artery embolization is an alternative, although frequently complicated by a ‘post-infarction syndrome’.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Recently, bilateral ureteral ligation<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> has been described, but the experience is limited and can induce persistent loin pain and ascending infections. Surgical nephrectomy is another option: although laparoscopic surgery is a less invasive procedure than an open nephrectomy, it precludes the chance for peritoneal dialysis and, consequently, we elected a bilateral nephrectomy by lombotomy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The histological examination of the kidneys revealed extensive presence of AA amyloid deposits comprising the glomeruli, the blood vessels and the interstitium, an infrequent finding in the review by Hopfer et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> who reported interstitium involvement in only 5.9%.</p><p id="par0035" class="elsevierStylePara elsevierViewall">AAA has a major impact in patient's quality of life: Esteve et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> reported that in 1/3 of the patients, dialysis was not performed due to their poor clinical condition and disturbing quality of life. Bilateral nephrectomy in our patient, led to an improvement in hemodynamic stability allowing hemodialysis to be accomplished. Additionally, her functional and nutritional status enhanced gradually.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Radical bilateral nephrectomy may be considered in seriously ill patients with nephrotic syndrome and disabling complications of proteinuria.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 626 "Ancho" => 1700 "Tamanyo" => 228234 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histological examination of the kidneys. (A) Glomerular nodular deposits of amyloid stained with Congo red. (B) Amyloid showing typical apple-green birefringence under polarized light.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Result \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reference range \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemoglobin (g/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–16 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leukocytes (<span class="elsevierStyleSmallCaps">10</span><span class="elsevierStyleSup">3</span>/μL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Platelets (<span class="elsevierStyleSmallCaps">10</span><span class="elsevierStyleSup">3</span>/μL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">183 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150–400 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C-reactive protein (mg/L/sedimentation rate 1st h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24/127 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><5/0–30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total protein/albumin (g/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.4/1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.4–8.3/3.5–5.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AST/ALT/LDH (U/L)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11/18/205 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–34/<55/110–220 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fasting glucose/total bilirubin (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83/0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60–110/0.2–1.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total/LDL/HDL cholesterol (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">270/169/40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><200/<100/≥60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urea/creatinine (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52/0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21–43/0.6–1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinalysis/24 hours protein (mg/day) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4+ proteinuria/19<span class="elsevierStyleHsp" style=""></span>538 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0+/<300 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum immunoelectrophoresis/serum kappa-lambda ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absence of monoclonal gammopathy/normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary electrophoresis/urinary immunoelectrophoresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Albumin<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>46% and gamma globulin<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14%/no band suggestive of monoclonality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tests for hepatitis B and C, HIV<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>, and syphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ANA, anti-dsDNA and ANCA<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> antibodies; C3 and C4 complement levels \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum amyloide A (mg/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1416481.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">AST: aspartate transaminase, ALT: alanine transaminase, LDH: lactate dehydrogenase.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">HIV: human immunodeficiency virus.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">ANA: antinuclear antibodies, anti-dsDNA: anti-double stranded DNA antibodies, ANCA: antineutrophil cytoplasmic antibodies.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Laboratory tests results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Amyloid nephropathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 3 | 1 | 4 |
| 2024 Octubre | 40 | 35 | 75 |
| 2024 Septiembre | 44 | 35 | 79 |
| 2024 Agosto | 67 | 54 | 121 |
| 2024 Julio | 38 | 20 | 58 |
| 2024 Junio | 74 | 31 | 105 |
| 2024 Mayo | 77 | 48 | 125 |
| 2024 Abril | 57 | 35 | 92 |
| 2024 Marzo | 50 | 27 | 77 |
| 2024 Febrero | 35 | 32 | 67 |
| 2024 Enero | 37 | 27 | 64 |
| 2023 Diciembre | 32 | 21 | 53 |
| 2023 Noviembre | 41 | 28 | 69 |
| 2023 Octubre | 41 | 27 | 68 |
| 2023 Septiembre | 21 | 32 | 53 |
| 2023 Agosto | 34 | 27 | 61 |
| 2023 Julio | 46 | 33 | 79 |
| 2023 Junio | 38 | 20 | 58 |
| 2023 Mayo | 45 | 32 | 77 |
| 2023 Abril | 42 | 14 | 56 |
| 2023 Marzo | 45 | 24 | 69 |
| 2023 Febrero | 47 | 28 | 75 |
| 2023 Enero | 37 | 23 | 60 |
| 2022 Diciembre | 45 | 35 | 80 |
| 2022 Noviembre | 49 | 44 | 93 |
| 2022 Octubre | 45 | 33 | 78 |
| 2022 Septiembre | 64 | 39 | 103 |
| 2022 Agosto | 67 | 48 | 115 |
| 2022 Julio | 40 | 53 | 93 |
| 2022 Junio | 47 | 31 | 78 |
| 2022 Mayo | 44 | 59 | 103 |
| 2022 Abril | 38 | 42 | 80 |
| 2022 Marzo | 62 | 55 | 117 |
| 2022 Febrero | 49 | 43 | 92 |
| 2022 Enero | 40 | 36 | 76 |
| 2021 Diciembre | 78 | 43 | 121 |
| 2021 Noviembre | 43 | 47 | 90 |
| 2021 Octubre | 53 | 42 | 95 |
| 2021 Septiembre | 56 | 48 | 104 |
| 2021 Agosto | 26 | 41 | 67 |
| 2021 Julio | 95 | 37 | 132 |
| 2021 Junio | 65 | 34 | 99 |
| 2021 Mayo | 45 | 42 | 87 |
| 2021 Abril | 95 | 69 | 164 |
| 2021 Marzo | 52 | 26 | 78 |
| 2021 Febrero | 37 | 31 | 68 |
| 2021 Enero | 60 | 27 | 87 |
| 2020 Diciembre | 37 | 11 | 48 |
| 2020 Noviembre | 45 | 18 | 63 |
| 2020 Octubre | 35 | 27 | 62 |
| 2020 Septiembre | 26 | 13 | 39 |
| 2020 Agosto | 42 | 12 | 54 |
| 2020 Julio | 31 | 21 | 52 |
| 2020 Junio | 34 | 24 | 58 |
| 2020 Mayo | 44 | 17 | 61 |
| 2020 Abril | 28 | 28 | 56 |
| 2020 Marzo | 41 | 17 | 58 |
| 2020 Febrero | 41 | 18 | 59 |
| 2020 Enero | 46 | 32 | 78 |
| 2019 Diciembre | 34 | 31 | 65 |
| 2019 Noviembre | 36 | 23 | 59 |
| 2019 Octubre | 27 | 8 | 35 |
| 2019 Septiembre | 25 | 18 | 43 |
| 2019 Agosto | 29 | 17 | 46 |
| 2019 Julio | 32 | 23 | 55 |
| 2019 Junio | 34 | 23 | 57 |
| 2019 Mayo | 30 | 17 | 47 |
| 2019 Abril | 50 | 28 | 78 |
| 2019 Marzo | 48 | 27 | 75 |
| 2019 Febrero | 40 | 16 | 56 |
| 2019 Enero | 28 | 14 | 42 |
| 2018 Diciembre | 183 | 37 | 220 |
| 2018 Noviembre | 428 | 21 | 449 |
| 2018 Octubre | 342 | 22 | 364 |
| 2018 Septiembre | 152 | 17 | 169 |
| 2018 Agosto | 82 | 16 | 98 |
| 2018 Julio | 68 | 14 | 82 |
| 2018 Junio | 99 | 18 | 117 |
| 2018 Mayo | 136 | 14 | 150 |
| 2018 Abril | 125 | 10 | 135 |
| 2018 Marzo | 185 | 10 | 195 |
| 2018 Febrero | 125 | 11 | 136 |
| 2018 Enero | 174 | 5 | 179 |
| 2017 Diciembre | 164 | 9 | 173 |
| 2017 Noviembre | 80 | 6 | 86 |
| 2017 Octubre | 53 | 8 | 61 |
| 2017 Septiembre | 61 | 11 | 72 |
| 2017 Agosto | 61 | 10 | 71 |
| 2017 Julio | 70 | 12 | 82 |
| 2017 Junio | 60 | 14 | 74 |
| 2017 Mayo | 74 | 22 | 96 |
| 2017 Abril | 67 | 8 | 75 |
| 2017 Marzo | 50 | 4 | 54 |
| 2017 Febrero | 57 | 5 | 62 |
| 2017 Enero | 45 | 8 | 53 |
| 2016 Diciembre | 62 | 10 | 72 |
| 2016 Noviembre | 129 | 16 | 145 |
| 2016 Octubre | 140 | 23 | 163 |
| 2016 Septiembre | 72 | 3 | 75 |
| 2016 Agosto | 29 | 3 | 32 |
| 2016 Julio | 55 | 7 | 62 |
| 2016 Junio | 34 | 0 | 34 |
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