Editorial
Incremental hemodialysis schedule at the start of renal replacement therapy
Hemodiálisis incremental como forma de inicio del tratamiento sustitutivo renal
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "5" "paginaFinal" => "8" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Es el sistema calicreína/quinina renal un factor modulador de la calciuria?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 1707 "Ancho" => 1502 "Tamanyo" => 105045 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Schematic model showing how tissue kallikrein participates in the regulation of the TRPV5 calcium epithelial channel in the late distal convoluted tubule. The tissue kallikrein produced by the connecting tubule is released into the urinary fluid. It is there that it acts on the filtered or locally secreted kininogen (KN) and finally produces bradykinin (BK). BK acts on its B2 receptor (BKRB<span class="elsevierStyleInf">2</span>), activating the phospholipase C/diacylglycerol/protein kinase C (PLC/DAG/PKC) pathway by inducing the TRPV5 calcium channel localisation at the apical membrane level and favours the reabsorption of tubular calcium. BK is degraded by neutral endopeptidase (NEP) and renal CYP kinase.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Armando Luis Negri" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Armando Luis" "apellidos" => "Negri" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0211699516300595" "doi" => "10.1016/j.nefro.2016.04.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699516300595?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251417300196?idApp=UINPBA000064" "url" => "/20132514/0000003700000001/v1_201703230033/S2013251417300196/v1_201703230033/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Incremental hemodialysis schedule at the start of renal replacement therapy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "4" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Milagros Fernández Lucas, José Luis Teruel" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Milagros" "apellidos" => "Fernández Lucas" "email" => array:1 [ 0 => "milagros.fernandez@salud.madrid.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "José Luis" "apellidos" => "Teruel" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Instituto de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad de Alcalá, Alcalá de Henares, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemodiálisis incremental como forma de inicio del tratamiento sustitutivo renal" ] ] "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" => 1359 "Ancho" => 1643 "Tamanyo" => 96963 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Incidence and prevalence of patients treated with 2 haemodialysis sessions a week.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Weekly frequency of haemodialysis</span><p id="par0005" class="elsevierStylePara elsevierViewall">At the EDTA Congress held in Florence in 1975, Cambi presented the results obtained with a haemodialysis regimen of 3 weekly sessions of 4<span class="elsevierStyleHsp" style=""></span>h duration.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> This report is not the most cited, but it is the one withg greatest impact in the history of haemodialysis. After 40 years have this regimen remains the usual scheme of regular haemodialysis, in both frequency and duration.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although performing 3 sessions per week is the conventional frequency in most haemodialysis units, an increase in the number of weekly sessions has been generally well-accepted by the nephrological community, and is considered a valid alternative for certain patients. However, a reduction in the weekly frequency of haemodialysis has always been controversial, even a taboo subject in Kalantar-Zadeh's opinion.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Data from DOPPS 4 show that the frequency of 3 weekly sessions is accepted by the overwhelming majority, and patients who dialyse less often are an anecdotal minority (data referring to Spain indicate that 8% of patients dialyse more than 3 days a week, and only 1% do so less often).<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">“Infrequent” haemodialysis</span><p id="par0015" class="elsevierStylePara elsevierViewall">It should be remembered that in 1985 Gotch established that based in the urea kinetic model an adequate dose of dialysis could be achieved with 2 weekly sessions providing that, the residual clearance of urea was equal to or greater than 2.5<span class="elsevierStyleHsp" style=""></span>mL/min.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Based on the DOPPS study and successive clinical guidelines it seems that this alternative have no many followers. The 2006 KDOQI Guideline evaluated the possibility of starting renal replacement therapy with 2 weekly haemodialysis sessions, when the residual clearance of urea<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> was greater than 3<span class="elsevierStyleHsp" style=""></span>mL/min/1.73<span class="elsevierStyleHsp" style=""></span>m.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> But this suggestion was no longer included in the 2015 KDOQI Guideline.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> For years, periodic measurement of renal clearance of urea has not formed part of the follow-up protocol in many haemodialysis units, among other reasons because residual renal function was considered to decline rapidly after commencement of regular HD so its determination had no value. This may be one of the reasons explaining the scant implementation of lower weekly frequency haemodialysis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Having in mind this background, it is interesting to see the increasing number of publications during the last 4 years, that show results obtained using less that 3 weekly HD sessions.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3,7–18</span></a> These articles have resulted in the publication of editorials, opinion articles and reviews which reveal real controversies<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19–24</span></a> in the field.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The experiences described in these publications should be classified into 2 groups that are totally different. In some articles, the number of weekly sessions of haemodialysis is adjusted to financial support.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3,7,9,11,15,17</span></a> Other publications describe the results obtained in patients that started renal replacement therapy with one or two weekly sessions with acceptable residual renal function, and increasing frequency as renal residual function was progressively reduced. This practice, similar to that performed for many years in many peritoneal dialysis units, is called incremental or progressive haemodialysis. To implement this scheme of dialysis it is necessary to have no financial constrain.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Incremental haemodialysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">One aspect highlighted by most of the published experiences is that starting treatment with incremental haemodialysis achieves better preservation of residual renal function.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10,12,13,18</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Preservation of residual renal function in patient on regular dialysis is important. It allows a greater fluid intake, it contributes to the elimination of medium and large uremic molecules, facilitates anemia correction Reduces inflammation, improves nutritional status, the control of blood pressure and quality of life, and it is a potent predictor of survival.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">25–27</span></a> Therefore the preservation of residual renal function has become one of the goals of haemodialysis treatment.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">As a result of better maintenance of residual renal function, incremental haemodialysis is associated with lower erythropoietin requirements,<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13,14</span></a> better nutritional parameters,<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,13</span></a> lower concentrations of beta-2-microglobulin,<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10,13,16</span></a> less volume overload according to interdialysis weight gain data,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,9,18</span></a> reduced hospitalization requirements,<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">13,14</span></a> better parameters quality of life<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> and survival rates equal to or greater than those achieved with the usual 3 weekly sessions.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">9,13,14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">It should be taken into consideration that all published work on incremental haemodialysis is observational and all have screening bias. Patients are excluded not only based on the renal function value at the start of haemodialysis treatment, but also if certain comorbidities are present.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">21,23</span></a> The inclusion criteria of the patients may influence the results, and the advantages observed with incremental haemodialysis should be analyzed carefully.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Our 10-year experience with incremental haemodialysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">At the beginning of 2006 we decided to apply incremental dialysis at the commencement of HD therapy. When a patient is admitted to the Haemodialysis Unit, a residual renal function study was performed. Two or three weekly sessions was scheduled depending on whether or not urea clearance exceeded 2.5<span class="elsevierStyleHsp" style=""></span>mL/min.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> Patients that were dialysed twice a week remained with this regimen until residual urea clearance was less than 2.5<span class="elsevierStyleHsp" style=""></span>mL/min or had clinical or laboratory abnormalities which prompted an increased frequency of treatment.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the initial periods of implementation of this guideline, we excluded cases with a history of heart failure and evidence of volume overload. With time we gained experience and confidence, and these patients have been enrolled in the incremental haemodialysis program; presently the only limiting factor from inclusion is the renal clearance of urea.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Residual renal function, glomerular filtration rate, is measured every 2 months as the mean of 24-h urea and creatinine clearance. The dialysis dose is calculated using the Daugirdas <span class="elsevierStyleItalic">K</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">t</span></span>/<span class="elsevierStyleItalic">V</span>, to which the renal clearance of urea contribution is added according to the formula recommended in the 2006 KDOQI guideline.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a> This total balanced <span class="elsevierStyleItalic">K</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">t</span></span>/<span class="elsevierStyleItalic">V</span> should be equal to or greater than 1.6, which is the minimum value indicated for the regimen of 2 weekly haemodialysis sessions in the Gotch<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a> and Casino<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> nomograms.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Using incremental haemodialysis, we have observed beneficial effects on anemia, beta-2-microglobulin concentration and hospitalization requirements <a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10,14</span></a>, without detecting a tendency to volume overload, measured by bioimpedance techniques or by biochemical circulatory volume markers.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,29</span></a> The latest version of UpToDate (2016)<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> recommends incorporating the measurement of renal function in the calculation of the dialysis dose received by haemodialysis patients, and cites the experience of our group, as we have found that the maintenance of residual renal function is similar between patients who start with 2 sessions of haemodialysis and those who start peritoneal dialysis.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows that the percentage of patients who started renal replacement therapy with 2 weekly sessions has increased from 29% to 76%, and that 20–25% of the patients treated in the hospital's haemodialysis unit are continuously being treated at this bi-weekly frequency.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">At 24 months after initiation of haemodialysis treatment, 35% of patients treated with incremental haemodialysis maintained a renal function that was sufficient to continue the regime of 2 weekly.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Our incremental haemodialysis program has been a pioneer in Spain and this experience has been disseminated through various publications.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">8,10,14,29</span></a> We are aware that other haemodialysis units in this country are interested in implementing this type of program and, in this same issue of the journal <span class="elsevierStyleSmallCaps">Nefrología [Nephrology]</span>, Merino et al. describe their experience with an incremental regimen similar to ours, and conclude that starting with 2 sessions a week can maintain residual diuresis, at least during the first year of haemodialysis treatment.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="par0085" class="elsevierStylePara elsevierViewall">Starting renal replacement therapy with 2 haemodialysis sessions per week with presevive increase in the frequency of dialysis session is an innovative clinical practice that changes the practice that has been used for more than 30 years. One of the main goals the preservation of residual renal function in patients who start haemodialysis, with the consequent clinical advantages associated with the maintenance of this renal function.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our experience, like the rest of the published works on incremental haemodialysis, is an observational study, with the screening bias determined by residual renal function at the commencement of renal replacement therapy. Although this does not invalidate the clinical findings obtained during these 10 years of experience, we believe that it is essential to back up these results with the greatest possible evidence, such as via a multicenter clinical trial that we have already implemented. Demonstrating the efficacy and safety of this regimen through a clinical trial would promote a wider dissemination within the nephrological community.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Weekly frequency of haemodialysis" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "“Infrequent” haemodialysis" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Incremental haemodialysis" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Our 10-year experience with incremental haemodialysis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández Lucas M, Teruel JL. Hemodiálisis incremental como forma de inicio del tratamiento sustitutivo renal. Nefrología. 2017;37:1–4.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1359 "Ancho" => 1643 "Tamanyo" => 96963 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Incidence and prevalence of patients treated with 2 haemodialysis sessions a week.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Short dialysis schedules (SDS) – finally ready to become routine?" 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 45 | 46 | 91 |
| 2024 September | 54 | 36 | 90 |
| 2024 August | 75 | 57 | 132 |
| 2024 July | 56 | 26 | 82 |
| 2024 June | 65 | 39 | 104 |
| 2024 May | 60 | 40 | 100 |
| 2024 April | 75 | 45 | 120 |
| 2024 March | 44 | 36 | 80 |
| 2024 February | 52 | 40 | 92 |
| 2024 January | 33 | 27 | 60 |
| 2023 December | 27 | 41 | 68 |
| 2023 November | 46 | 37 | 83 |
| 2023 October | 36 | 32 | 68 |
| 2023 September | 32 | 28 | 60 |
| 2023 August | 45 | 26 | 71 |
| 2023 July | 43 | 22 | 65 |
| 2023 June | 43 | 22 | 65 |
| 2023 May | 62 | 40 | 102 |
| 2023 April | 24 | 13 | 37 |
| 2023 March | 63 | 21 | 84 |
| 2023 February | 55 | 20 | 75 |
| 2023 January | 76 | 26 | 102 |
| 2022 December | 71 | 30 | 101 |
| 2022 November | 47 | 38 | 85 |
| 2022 October | 60 | 47 | 107 |
| 2022 September | 55 | 35 | 90 |
| 2022 August | 67 | 46 | 113 |
| 2022 July | 51 | 41 | 92 |
| 2022 June | 59 | 35 | 94 |
| 2022 May | 87 | 48 | 135 |
| 2022 April | 103 | 50 | 153 |
| 2022 March | 89 | 50 | 139 |
| 2022 February | 69 | 57 | 126 |
| 2022 January | 71 | 39 | 110 |
| 2021 December | 107 | 44 | 151 |
| 2021 November | 115 | 43 | 158 |
| 2021 October | 69 | 52 | 121 |
| 2021 September | 58 | 47 | 105 |
| 2021 August | 43 | 47 | 90 |
| 2021 July | 49 | 46 | 95 |
| 2021 June | 43 | 30 | 73 |
| 2021 May | 77 | 51 | 128 |
| 2021 April | 196 | 113 | 309 |
| 2021 March | 135 | 53 | 188 |
| 2021 February | 87 | 43 | 130 |
| 2021 January | 93 | 31 | 124 |
| 2020 December | 63 | 21 | 84 |
| 2020 November | 64 | 25 | 89 |
| 2020 October | 59 | 27 | 86 |
| 2020 September | 69 | 19 | 88 |
| 2020 August | 49 | 18 | 67 |
| 2020 July | 59 | 22 | 81 |
| 2020 June | 76 | 30 | 106 |
| 2020 May | 106 | 24 | 130 |
| 2020 April | 58 | 28 | 86 |
| 2020 March | 65 | 22 | 87 |
| 2020 February | 48 | 21 | 69 |
| 2020 January | 90 | 32 | 122 |
| 2019 December | 65 | 29 | 94 |
| 2019 November | 78 | 26 | 104 |
| 2019 October | 71 | 20 | 91 |
| 2019 September | 86 | 31 | 117 |
| 2019 August | 61 | 27 | 88 |
| 2019 July | 55 | 19 | 74 |
| 2019 June | 47 | 40 | 87 |
| 2019 May | 53 | 40 | 93 |
| 2019 April | 99 | 59 | 158 |
| 2019 March | 81 | 45 | 126 |
| 2019 February | 50 | 28 | 78 |
| 2019 January | 52 | 37 | 89 |
| 2018 December | 187 | 63 | 250 |
| 2018 November | 295 | 55 | 350 |
| 2018 October | 304 | 22 | 326 |
| 2018 September | 121 | 30 | 151 |
| 2018 August | 67 | 28 | 95 |
| 2018 July | 81 | 20 | 101 |
| 2018 June | 95 | 21 | 116 |
| 2018 May | 165 | 17 | 182 |
| 2018 April | 186 | 15 | 201 |
| 2018 March | 179 | 20 | 199 |
| 2018 February | 148 | 14 | 162 |
| 2018 January | 130 | 10 | 140 |
| 2017 December | 170 | 14 | 184 |
| 2017 November | 84 | 15 | 99 |
| 2017 October | 35 | 14 | 49 |
| 2017 September | 55 | 19 | 74 |
| 2017 August | 55 | 13 | 68 |
| 2017 July | 57 | 16 | 73 |
| 2017 June | 58 | 6 | 64 |
| 2017 May | 63 | 21 | 84 |
| 2017 April | 49 | 9 | 58 |
| 2017 March | 47 | 5 | 52 |
| 2017 February | 21 | 6 | 27 |
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