Original article
Magnesium changes during hemodialysis alter the QTc interval and QTc dispersion
Los cambios de la concentración de magnesio durante la hemodiálisis alteran el intervalo Qtc y la dispersión de Qtc
Basturk Taner
, Unsal Abdulkadir, Koc Yener, Sakaci Tamer, Yilmaz Murvet, Ahbap Elbis
Corresponding author
Department of Nephrology, Sisli Etfal Research and Education, Istanbul, Turkey
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la ministra de Sanidad y Política Social, Doña Trinidad Jiménez García-Herrera, y el Dr. Rafael Matesanz-Acedos (director de la ONT).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Julen Ocharan-Corcuera" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Julen" "apellidos" => "Ocharan-Corcuera" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1886284511002189?idApp=UINPBA00004N" "url" => "/18862845/0000003200000004/v1_201304291617/S1886284511002189/v1_201304291617/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Magnesium changes during hemodialysis alter the QTc interval and QTc dispersion" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "142" "paginaFinal" => "146" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Basturk Taner, Unsal Abdulkadir, Koc Yener, Sakaci Tamer, Yilmaz Murvet, Ahbap Elbis" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Basturk" "apellidos" => "Taner" "email" => array:1 [ 0 => "tanerbast@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Unsal" "apellidos" => "Abdulkadir" ] 2 => array:2 [ "nombre" => "Koc" "apellidos" => "Yener" ] 3 => array:2 [ "nombre" => "Sakaci" "apellidos" => "Tamer" ] 4 => array:2 [ "nombre" => "Yilmaz" "apellidos" => "Murvet" ] 5 => array:2 [ "nombre" => "Ahbap" "apellidos" => "Elbis" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Department of Nephrology, Sisli Etfal Research and Education, Istanbul, Turkey" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Los cambios de la concentración de magnesio durante la hemodiálisis alteran el intervalo Qtc y la dispersión de Qtc" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1417 "Ancho" => 1319 "Tamanyo" => 77336 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The means of OTc interval of study patients.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mortality risk related to cardiovascular disease in patients having kidney insufficiency is 10-fold higher compared with overall population, vast majority of death events comprise heart insufficiency, myocardium infarction and sudden cardiac deaths.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Responsible mechanism for the sudden increase in risk of cardiac death is not completely known and also, at the end of the Holter monitoring, during hemodialysis and just after it arrhythmia and high incidence of early ventricular pulses were shown. During dialysis there is rapid change in intracellular and extracellular electrolytes causing these arrhythmias.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">QTc interval and QTc dispersion measurements are non-invasive methods. This is non-invasive measurement of myocardial repolarization in homogeneity and hence predisposition to re-entry arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The purpose of our study was to determine the QTc interval and QTc dispersion in CKD and HD patients, and to assess the effect of HD on QTc interval and QTc dispersion.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and method</span><p id="par0020" class="elsevierStylePara elsevierViewall">This cross-sectional study was performed in Department of Nephrology between May 2008 and October 2008. Twenty-five HD patients (13 males, mean age: 43.04<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.04 years) and 20 CKD patients (9 males, mean age: 45.51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.84 years, mean GFR: 42.05<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>24.6<span class="elsevierStyleHsp" style=""></span>ml/min) were enrolled in the study. The patients signed a written informed consent form to participate in the study. The study was approved by the local ethics committee.</p><p id="par0025" class="elsevierStylePara elsevierViewall">All patients were usually treated with a dialytic regimen of bicarbonate dialysis at the following electrolyte concentrations in the bath: K<span class="elsevierStyleSup">+</span>, 2.0<span class="elsevierStyleHsp" style=""></span>mmol/l; Ca<span class="elsevierStyleSup">2+</span>, 1.5<span class="elsevierStyleHsp" style=""></span>mmol/l; Mg<span class="elsevierStyleSup">2+</span>, 0.5<span class="elsevierStyleHsp" style=""></span>mmol/l; HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">−</span>, 32<span class="elsevierStyleHsp" style=""></span>mmol/l; F60 (Polysulfon) dialysers, blood flow 350<span class="elsevierStyleHsp" style=""></span>ml/min, dialysate flow 500<span class="elsevierStyleHsp" style=""></span>ml/min. All subjects were on HD treatment for at least 3 months and they performed 4<span class="elsevierStyleHsp" style=""></span>h HD sessions three times a week. Twenty CKD patients were normotensive with GFR 59–15<span class="elsevierStyleHsp" style=""></span>ml/min (stages 3 and 4).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Exclusion criteria were (i) diabetes, (ii) overt ischaemic heart disease (IHD), (iii) ECG evidence of left ventricular hypertrophy (LVH) or left bundle-branch block (LBBB), (iv) atrial fibrillation, (v) patients taking class I or class III anti-arrhythmic drugs, and (vi) patients taking anti-hypertensives.</p><p id="par0035" class="elsevierStylePara elsevierViewall">ECGs of the patients with CKD coming to policlinic follow-up were taken at a speed of 25<span class="elsevierStyleHsp" style=""></span>mm/s and taking their blood samples their plasma electrolyte levels (K<span class="elsevierStyleSup">+</span>, Ca<span class="elsevierStyleSup">2</span>, Mg<span class="elsevierStyleSup">2</span>) were detected on the same day. Standard dialysis was performed for 4<span class="elsevierStyleHsp" style=""></span>h, three times a week. Twelve-lead ECGs were performed (Hewlett-Packard Page writer 100 with a 25<span class="elsevierStyleHsp" style=""></span>mm/s paper speed, gain 10<span class="elsevierStyleHsp" style=""></span>mm/mV) under identical conditions for all patients: 30<span class="elsevierStyleHsp" style=""></span>min before and 30<span class="elsevierStyleHsp" style=""></span>min after the morning, mid-week HD session.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The QT interval was measured from the onset of the QRS complex to the end of the T wave, defined by the return of the terminal T wave to the isoelectric TP baseline. When U waves were present, the end of the T wave was taken as the nadir between the T and U waves. If the end of the T wave was not clear in a particular lead then it was excluded from analysis; for any particular ECG, no more than three leads were excluded. Three successive QT interval measurements were performed in each of the 12 leads, and the mean value was calculated. The maximum QT interval was corrected for heart rate (QTc-max) using Bazett's formula QTc<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>QT/(RR)<span class="elsevierStyleSup">1/2</span>. The QT (QTc) dispersion was determined as the difference between the maximum and the minimum of the QT (QTc) in different leads (minimum 10) on the same recording. All ECGs were manually investigated by one person.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Serum potassium, calcium, magnesium, creatinine and albumin were measured with an autoanalyzer. Calcium was corrected for hypoalbuminemia by adding 0.8<span class="elsevierStyleHsp" style=""></span>mg/dl to the calcium concentration for each 1<span class="elsevierStyleHsp" style=""></span>g/dl decrease in albumin concentration from the normal 4.0<span class="elsevierStyleHsp" style=""></span>g/dl.</p><p id="par0050" class="elsevierStylePara elsevierViewall">CKD was defined according to the presence or absence of kidney damage and the level of kidney function. Kidney damage was defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Among individuals with CKD, the stage was defined by the level of e-GFR (stages 1–5). Estimated glomerular filtration rate (e-GFR) was calculated by using the Cockcroft and Gault formula.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistics</span><p id="par0055" class="elsevierStylePara elsevierViewall">For statistical study SPSS 13.0 packet computer statistic program was used. Results are expressed as a mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>sd. Statistical evaluation was performed with the two-tailed paired and unpaired Student's test and Pearson correlation test. Differences were considered as statistically significant when the <span class="elsevierStyleItalic">p</span> value was <0.05.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">In the HD patients, chronic glomerulonephritis and polycystic kidney disease, in the CKD patients, chronic glomerulonephritis and tubulointerstitial nephritis were the most common causes. We did not found significant difference in age and gender, as compared to all of patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).In 5 of the patients with CKD abnormally prolonged QTc interval was found. In addition to the prolonged QTc dispersion was detected in three patients. Among pre-HD patients, 14 patients prolonged QT interval, and 12 patients had prolonged QTc dispersion.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In patients with HD, QTc interval was prolonged in pre- (446<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>53<span class="elsevierStyleHsp" style=""></span>ms) and post-HD patients (470<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>51<span class="elsevierStyleHsp" style=""></span>ms) compared to the patients with CKD (408<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>ms) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Pre and post HD in terms of QTc dispersion, there was no statistically significant variation between the patients with HD (42<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15/45<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>ms) and CKD (39<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>ms) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">QTc interval was prolonged significantly in post-HD compared to pre-HD (470<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>51<span class="elsevierStyleHsp" style=""></span>ms vs 446<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5 3<span class="elsevierStyleHsp" style=""></span>ms) (<span class="elsevierStyleItalic">p</span>: 0.007) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This increase in QTc interval was not homogeneous; QTc interval increased in 16 patients, it reduced in 5 patients reduced, in 4 patients did not change.</p><p id="par0080" class="elsevierStylePara elsevierViewall">No significant difference was found in QTc dispersion post-HD (45<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>ms) compared to pre-HD (42<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>ms) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05). Post-HD while QTc dispersion increased in 12 patients, it remained constant in 2 patients, and decreased in the remaining 11 patients (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0085" class="elsevierStylePara elsevierViewall">The serum K<span class="elsevierStyleSup">+</span> (5.62<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.94 and 3.35<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.72<span class="elsevierStyleHsp" style=""></span>mEql/l, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) and Mg<span class="elsevierStyleSup">2</span> (3.06<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.75 and 2.43<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.58<span class="elsevierStyleHsp" style=""></span>mg/dl <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001) concentrations significantly decreased, whereas the Ca<span class="elsevierStyleSup">2+</span> (8.31<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.63 and 9.68<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.87<span class="elsevierStyleHsp" style=""></span>mg/dl, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), concentrations significantly increased in post-HD compared to pre-HD patients.</p><p id="par0090" class="elsevierStylePara elsevierViewall">After HD, in patients with prolonged QTc interval (<span class="elsevierStyleItalic">n</span>: 16; 478<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>55<span class="elsevierStyleHsp" style=""></span>ms) and QTc dispersion (<span class="elsevierStyleItalic">n</span>: 14; 52<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>ms), serum Mg levels decreased (2.99 <span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.87/2.30<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.35<span class="elsevierStyleHsp" style=""></span>mg/dl and 3.01<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.63/2.20<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.43<span class="elsevierStyleHsp" style=""></span>mg/dl, respectively). There was significant correlation between the prolonged QTc interval and QTc dispersion and serum Mg level changes (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.326, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Our study demonstrates that, HD patients (pre-HD and post-HD) had an abnormally prolonged QT interval compared to CKD patients. In patients with prolonged QT interval and QT dispersion after HD, only the level of Mg<span class="elsevierStyleSup">2</span> significantly decreased.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Patients with advanced CKD have increased cardiovascular mortality of multifactorial aetiology including cardiac arrhythmia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Prolonged QT interval may be responsible for some of the cardiac deaths. The QT interval is a measure of the duration of ventricular depolarization and repolarization, and prolongation of the QT interval can predict cardiovascular death. QT dispersion is a marker of variability of ventricular repolarization and is known to be increased in various high-risk groups. Moreover recently these electrical markers were found to be independent predictors of total and cardiovascular mortality in both nonuremia and ureamic populations.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The normal QTc interval varies from 350 to 450 milliseconds (ms). The normal range for QT dispersion is 40–50<span class="elsevierStyleHsp" style=""></span>ms with a maximum of 65<span class="elsevierStyleHsp" style=""></span>ms. In our study, HD and CRF patients were found to have longer QT interval and QT dispersion, so this group of patients may be at higher risk of sudden cardiac death and ventricular arrhythmia.</p><p id="par0110" class="elsevierStylePara elsevierViewall">As a result of the studies conducted, in HD patients, compared with normal healthy individuals, QTc interval and QTc dispersion as a predisposal for sudden cardiac death and intensified ventricular arrhythmia were found long, and among the samples having long QTc interval and QTc dispersion cardiovascular death and cardiac morbidity were found to be higher.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The hemodialysis patients have a wide variety of ECG abnormalities and, in certain instances; hemodialysis itself seems to be a cause of ECG changes and different kinds of dysrhythmias.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Cardiac arrhythmia is more frequent in HD patients, during HD in intracellular and extracellular electrolytes, especially related to fast alterations emerged subject to dialyzable cations’; Ca, Mg and K concentrations, it had the possibility to emerge during HD and just after HD.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Yetkin et al. showed that after HD a significant correlation between the increase in QTc interval, QTc dispersion and serum electrolyte variants occurred, and this relation might provide new insights into the evaluation of the ionic bases involved in inhomogeneous ventricular repolarization.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Covic et al., in their study carried out over 68 non-diabetic patients found that, the increase in HD patients’ QTc interval was most of the times related with the rapid change in plasma electrolyte concentration, and impact over QTc dispersion was found less significant.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In our study; the mean of pre- and post-dialysis cycle QT interval increased significantly (<span class="elsevierStyleItalic">p</span>: 0.007), there was no change in QT dispersion (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05). This change in QTc interval and QT dispersion was not homogeneous. Prolonged QT interval, a measure of heterogeneity of vascular repolarization, has been linked with increased risk of sudden death in dialyzed patients and it may be more prolonged, after hemodialysis.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The serum K<span class="elsevierStyleSup">+</span> and Mg<span class="elsevierStyleSup">2</span> concentrations significantly decreased, whereas the Ca<span class="elsevierStyleSup">2+</span> concentrations significantly increased. In post-HD patients with prolonged QT interval and QT dispersion, only the level of Mg<span class="elsevierStyleSup">2</span> significantly decreased. The level of serum K<span class="elsevierStyleSup">+</span> and Ca<span class="elsevierStyleSup">2+</span> showed no significant difference.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Potassium and magnesium are two of the most important factors for the electrical stability of the myocardium, involved in creating normal cellular excitability, impulse propagation, and regular ventricular recovery.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Magnesium depletion in general is associated with changes in the ECG. Widening of the QRS complex and peaking of T waves have been described with modest magnesium loss, whereas more severe magnesium depletion can lead to prolongation of the PR and QT intervals, progressive widening of the QRS complex, and diminution of the T wave.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Possible candidates for this are free fatty acids<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> catecholamines, and sympathetic stimulation.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Cardiac arrhythmias are an important complication of magnesium depletion. This is an important concept because increases in QTc and QTc dispersion suggest that ventricular repolarization is delayed when intracellular magnesium concentrations are low, leading to increased risk for developing ventricular arrhythmia. In addition magnesium levels alter the generation of potassium into the cell through the membrane ATP. QT interval elongation in magnesium deficiency possibly arises from the incomplete membrane transportation of potassium.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> Cupisti et al. have suggested that magnesium could be the main cause of increased QT dispersion.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0150" class="elsevierStylePara elsevierViewall">Our study demonstrates that, HD patients (pre-HD and post-HD) had an abnormally prolonged QT interval compared to CKD patients.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0155" class="elsevierStylePara elsevierViewall">Hemodialysis increases the QTc interval in ESRD patients. However, the impact on QTc dispersion is not important. These changes are not homogeneous.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0160" class="elsevierStylePara elsevierViewall">The prolonged QT interval and QT dispersion in post-HD patients were only reduced at the level of Mg. The low Mg level may predispose HD patients to risk factor for cardiac arrhythmias. Therefore, further studies with different concentration of Mg<span class="elsevierStyleSup">2</span> containing dialysate (i.e. 0.75/1<span class="elsevierStyleHsp" style=""></span>mmol/l) should be made.</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres104421" "titulo" => array:3 [ 0 => "Abstract" 1 => "Results" 2 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec91835" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres104422" "titulo" => array:4 [ 0 => "Resumen" 1 => "Fundamento" 2 => "Resultados" 3 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec91836" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistics" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-05-18" "fechaAceptado" => "2011-06-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec91835" "palabras" => array:4 [ 0 => "QTc interval" 1 => "QTc dispersion" 2 => "Hemodialysis" 3 => "CKD" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec91836" "palabras" => array:4 [ 0 => "Intervalo QTc" 1 => "dispersión QTc" 2 => "Hemodiálisis" 3 => "NPC" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The purpose of our study was to determine the QTc interval, QTc dispersion in CKD and HD patients, and to assess the effect of HD on QTc interval, QTc dispersion. Twenty-five HD and 20 CKD patients were included in the study. Serum concentrations of K<span class="elsevierStyleSup">+</span>, Ca<span class="elsevierStyleSup">2</span>, Mg<span class="elsevierStyleSup">2</span>, creatinine, and albumin were monitored and QT interval and QT dispersion were measured from 12 lead ECG.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In 5 of the patients with CKD abnormally prolonged QTc interval was found. In addition to the prolonged QTc dispersion was detected in three patients. Among pre-HD patients, 14 patients had prolonged QT interval, and 12 had QTc dispersion. The HD patients (pre-HD and post-HD) were found to have prolonged QTc interval compared to patients with CKD (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">QTc interval increased significantly in post-HD, compared to pre-HD (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.007). This increase in QTc interval was not homogeneous; QTc interval increased in 16 patients, it reduced in 5 patients, in 4 patients it did not change.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">No significant difference in QTc dispersion was found in post-HD compared to pre-HD (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.05). Post-HD while QTc dispersion increased in 14 patients, remained constant in 2 patients, in the remaining 11 patients decreased.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The patients with prolonged QT interval (<span class="elsevierStyleItalic">n</span>: 16) and QT dispersion (<span class="elsevierStyleItalic">n</span>: 14) in post-HD, only at the level of Mg<span class="elsevierStyleSup">2</span> significantly decreased (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.01).</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">HD patients (pre-HD and post-HD) had an abnormally prolonged QT interval compared to CKD patients.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The patients with prolonged QT interval and QT dispersion in after HD, only at the level of Mg<span class="elsevierStyleSup">2</span> significantly decreased. The low Mg level may predispose HD patients to risk factor for cardiac arrhythmias.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Fundamento</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El objetivo del presente estudio fue determinar el intervalo QTc, la dispersión de QTc en pacientes con nefropatía crónica (NPC) y en pacientes sometidos a hemodiálisis (HD) y valorar el efecto de la HD sobre el intervalo QTc y dispersión de QTc. En el estudio se incluyeron 25 pacientes HD y 20 NPC. Se monitorizaron las concentraciones séricas de K<span class="elsevierStyleSup">+</span>, Ca<span class="elsevierStyleSup">2</span>, Mg<span class="elsevierStyleSup">2</span>, creatinina y albúmina y se determinaron el intervalo QT y la dispersión QT a partir de un electrocardiograma (ECG) de 12 derivaciones.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En cinco de los pacientes con NPC se detectó un intervalo QTc prolongado anormalmente. Además, en tres pacientes se detectó dispersión QTc prolongada. Entre pacientes pre-HD, en 14 se detectó un intervalo QT prolongado y en 12, una dispersión QT prolongada. Los pacientes HD (pre-HD y post-HD) manifestaron un intervalo QTc prolongado, comparado con los pacientes NPC (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001).</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El intervalo QTc aumentó significativamente después de la HD, comparado con antes de ella (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,007). Este aumento del intervalo QTc no fue homogéneo; el intervalo QTc de 16 pacientes aumentó, en cinco disminuyó y en cuatro no se modificó.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">No se observó una diferencia significativa de la dispersión QTc post-HD en comparación con pre-HD (p<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0,05). Mientras que la dispersión QTc post-HD aumentó en 14 pacientes, permaneció constante en dos y en los 11 pacientes restantes disminuyó.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">En el período post-HD, en los pacientes con prolongación del intervalo QT (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) y dispersión de QT (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14), solo se identificó una disminución significativa de la concentración de Mg<span class="elsevierStyleSup">2</span> (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,01).</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">En pacientes HD (pre-HD y post-HD) se identificó una prolongación anómala del intervalo QT en comparación con pacientes NPC.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">En los pacientes con prolongación del intervalo QT y dispersión de QT después de HD, solo se detectó una disminución significativa de la concentración de Mg<span class="elsevierStyleSup">2</span>. La baja concentración de Mg puede predisponer a los pacientes HD a un factor de riesgo de arritmias cardíacas.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1417 "Ancho" => 1319 "Tamanyo" => 77336 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">The means of OTc interval of study patients.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1611 "Ancho" => 1417 "Tamanyo" => 89122 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">The means of OTc dispersion of study patients.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">HD patients (<span class="elsevierStyleItalic">n</span>: 25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">CRF patient (<span class="elsevierStyleItalic">n</span>: 20) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender (M/F) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15/10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11/9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age (yr) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.04<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.51<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.84 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Causes of renal failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic glomerulonephritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tubulointerstitial nephritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polycystic kidney disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obstructive nephropaty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab186309.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of the study patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 2 | 6 |
| 2024 October | 12 | 3 | 15 |
| 2024 September | 29 | 2 | 31 |
| 2024 August | 28 | 6 | 34 |
| 2024 July | 18 | 4 | 22 |
| 2024 June | 15 | 7 | 22 |
| 2024 May | 18 | 2 | 20 |
| 2024 April | 21 | 7 | 28 |
| 2024 March | 19 | 6 | 25 |
| 2024 February | 16 | 6 | 22 |
| 2024 January | 18 | 7 | 25 |
| 2023 December | 12 | 11 | 23 |
| 2023 November | 19 | 8 | 27 |
| 2023 October | 17 | 16 | 33 |
| 2023 September | 23 | 7 | 30 |
| 2023 August | 24 | 5 | 29 |
| 2023 July | 6 | 13 | 19 |
| 2023 June | 15 | 7 | 22 |
| 2023 May | 33 | 4 | 37 |
| 2023 April | 31 | 3 | 34 |
| 2023 March | 24 | 6 | 30 |
| 2023 February | 19 | 9 | 28 |
| 2023 January | 17 | 7 | 24 |
| 2022 December | 20 | 14 | 34 |
| 2022 November | 19 | 13 | 32 |
| 2022 October | 21 | 11 | 32 |
| 2022 September | 23 | 22 | 45 |
| 2022 August | 34 | 11 | 45 |
| 2022 July | 29 | 12 | 41 |
| 2022 June | 20 | 8 | 28 |
| 2022 May | 14 | 14 | 28 |
| 2022 April | 10 | 11 | 21 |
| 2022 March | 16 | 13 | 29 |
| 2022 February | 16 | 11 | 27 |
| 2022 January | 17 | 8 | 25 |
| 2021 December | 11 | 10 | 21 |
| 2021 November | 28 | 19 | 47 |
| 2021 October | 21 | 16 | 37 |
| 2021 September | 14 | 15 | 29 |
| 2021 August | 10 | 11 | 21 |
| 2021 July | 14 | 11 | 25 |
| 2021 June | 33 | 9 | 42 |
| 2021 May | 18 | 8 | 26 |
| 2021 April | 37 | 30 | 67 |
| 2021 March | 29 | 13 | 42 |
| 2021 February | 26 | 10 | 36 |
| 2021 January | 27 | 20 | 47 |
| 2020 December | 8 | 10 | 18 |
| 2020 November | 13 | 14 | 27 |
| 2020 October | 14 | 8 | 22 |
| 2020 September | 16 | 10 | 26 |
| 2020 August | 13 | 8 | 21 |
| 2020 July | 13 | 5 | 18 |
| 2020 June | 16 | 11 | 27 |
| 2020 May | 9 | 10 | 19 |
| 2020 April | 15 | 8 | 23 |
| 2020 March | 22 | 6 | 28 |
| 2020 February | 14 | 13 | 27 |
| 2020 January | 18 | 25 | 43 |
| 2019 December | 20 | 15 | 35 |
| 2019 November | 14 | 7 | 21 |
| 2019 October | 16 | 1 | 17 |
| 2019 September | 25 | 5 | 30 |
| 2019 August | 18 | 10 | 28 |
| 2019 July | 12 | 24 | 36 |
| 2019 June | 43 | 39 | 82 |
| 2019 May | 105 | 53 | 158 |
| 2019 April | 31 | 20 | 51 |
| 2019 March | 13 | 5 | 18 |
| 2019 February | 11 | 11 | 22 |
| 2019 January | 8 | 6 | 14 |
| 2018 December | 10 | 12 | 22 |
| 2018 November | 6 | 9 | 15 |
| 2018 October | 9 | 16 | 25 |
| 2018 September | 11 | 1 | 12 |
| 2018 August | 5 | 0 | 5 |
| 2018 July | 5 | 4 | 9 |
| 2018 June | 8 | 1 | 9 |
| 2018 May | 4 | 6 | 10 |
| 2018 April | 4 | 0 | 4 |
| 2018 March | 1 | 3 | 4 |
| 2018 February | 6 | 6 | 12 |
| 2018 January | 9 | 6 | 15 |
| 2017 December | 10 | 1 | 11 |
| 2017 November | 7 | 5 | 12 |
| 2017 October | 13 | 3 | 16 |
| 2017 September | 8 | 8 | 16 |
| 2017 August | 11 | 4 | 15 |
| 2017 July | 15 | 1 | 16 |
| 2017 June | 12 | 12 | 24 |
| 2017 May | 22 | 10 | 32 |
| 2017 April | 22 | 11 | 33 |
| 2017 March | 13 | 23 | 36 |
| 2017 February | 15 | 2 | 17 |
| 2017 January | 20 | 5 | 25 |
| 2016 December | 28 | 6 | 34 |
| 2016 November | 29 | 5 | 34 |
| 2016 October | 40 | 8 | 48 |
| 2016 September | 33 | 4 | 37 |
| 2016 August | 23 | 5 | 28 |
| 2016 July | 16 | 1 | 17 |
| 2016 June | 18 | 5 | 23 |
| 2016 May | 13 | 17 | 30 |
| 2016 April | 16 | 11 | 27 |
| 2016 March | 12 | 13 | 25 |
| 2016 February | 7 | 13 | 20 |
| 2016 January | 10 | 14 | 24 |
| 2015 December | 8 | 10 | 18 |
| 2015 November | 12 | 9 | 21 |
| 2015 October | 21 | 19 | 40 |
| 2015 September | 20 | 8 | 28 |
| 2015 August | 11 | 6 | 17 |
| 2015 July | 7 | 2 | 9 |
| 2015 June | 7 | 2 | 9 |
| 2015 May | 17 | 2 | 19 |
| 2015 April | 8 | 3 | 11 |
| 2015 March | 12 | 4 | 16 |
| 2015 February | 25 | 4 | 29 |
| 2015 January | 33 | 3 | 36 |
| 2014 December | 32 | 7 | 39 |
| 2014 November | 19 | 3 | 22 |
| 2014 October | 36 | 7 | 43 |
| 2014 September | 38 | 2 | 40 |
| 2014 August | 13 | 3 | 16 |
| 2014 July | 32 | 3 | 35 |
| 2014 June | 35 | 2 | 37 |
| 2014 May | 16 | 2 | 18 |
| 2014 April | 23 | 5 | 28 |
| 2014 March | 25 | 1 | 26 |
| 2014 February | 32 | 3 | 35 |
| 2014 January | 20 | 2 | 22 |
| 2013 December | 33 | 3 | 36 |
| 2013 November | 24 | 0 | 24 |
| 2013 October | 55 | 4 | 59 |
| 2011 September | 546 | 0 | 546 |
Show all