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Good morning to everyone. I am pleased to be here today to present you our study about clinical outcomes after parathyroidectomy in chronic hemodialysis patients Let me introduce myself first, I am doctor Azza Khedhiri, nephrologist in Sfax CNSS polyclinic and I have no conflicts of interest To get started, you all know that secondary hyperparathyroidism is one of the majors’ complications of chronic kidney disease, especially in predialysis and dialysis patients. Currently, KDIGO guidelines still indicate parathyroidectomy for severe hyperparathyroidism that resists to medical therapies. Even though beneficial effects on biological parameters were well assessed, the different clinical outcomes of this procedure are still lacking Therefore, we conducted this study to describe preoperative profile of patients, evaluate short and long term postoperative clinical courses, and finally to analyze the different biological and clinical outcomes. This study included retrospectively all patients who underwent PTX between January two thousands and eight and September twenty twenty-one and who had a follow up for at least one year after surgery. We described patients’ characteristics, circumstances of the procedure, immediate post op course, long term outcomes: one year post discharge or more. And I guess the relevance of this study is the analysis of bone density. We even compared bone density in PTX patients and non-operated hyper parathyroid patients in the same unit. Nine patients underwent PTX, five men and four women with a mean age at fifty-one years. We colligated all in all twenty-four patients with hyperparathyroidism in our unit, so a prevalence of PTX in our population at thirty-seven% The mean duration of dialysis before the first PTX was almost thirteen years. The main Clinical signs that occurred before PTX were bone pain and arthropathy associated with severe pruritus in 5 cases (55%). But the most dramatical sign that motivated especially patients themselves to accept the surgery was the occurrence of pathological bone fracture in 5 cases. We even witnessed a femoral spontaneous fracture in one of the patients while he was simply sleeping. Concerning biological signs, we had obviously a medical therapy resistant and severe hyperparathyroidism with tertiary profile in 4 patients [All patients were resistant to more conservative measures, including control of serum phosphate, attention to oral intake and dialysate calcium levels, and oral administration of active vitamin-D-pulse therapy.] Ultrasound revealed adenoma in 2 cases and nodules in 7 cases, parathyroid technetium scan performed in only 6 cases confirmed ultrasound results and showed ectopic location in one case Subtotal PTX(7/8th) was performed in 6 patients (66%) and selective PTX(3/4th) in 3cases. The mean hospital stay was 4.14 ± 1.05 days. Regarding biological tests, it’s clear here that the reduce in PTH is significant (p<0,05). Serum calcium levels are slightly elevated in pre-op (2.6) because of the considerable rate of tertiary while it becomes slightly low (2.08) after one year. Serum phosphorus also decreased considerably, same thing for alkaline phosphatases Here is a summary of the most important complications that occurred in the first year. In chronological order the first three patients had the oldest surgeries so they had the selective technique which is the oldest technique. The three of them had severe hypocalcemia, which progressed to hungry bone syndrome in the first two and in the three cases recurrence occurred more or less rapidly. The three of them were reoperated. A more recent procedure in patient 4, this time a subtotal technique and this time you will notice that instead of recurrence patient developed hypoparathyroidism and adynamic osteopathy within a year. Same thing for patient 5. Patient 6 had a better luck I guess because with time post op care is better. So, he had quite favorable evolution from the third month. Most recent procedures for the last three patients, during 2020. They had for common a symptomatic hypothyroidism treated with replacement hormone therapy. I don’t know if it’s related to the surgery technique or if it’s because we started thinking about this complication regarding to typical and persistent post op hypothyroidism’s signs. Patient 8 had the most favorable outcome; he had no hypocalcemia neither hypoparathyroidism. Patient 9 however had a deep hungry bone syndrome And now what about bone fractures, you can see here that before PTX 6 bones fractures in total happened versus 3 only after PTX. Concerning bone density analysis, here I put the lowest T-score measured in all the examined sites and as you can see, T scores are relatively low. And three patients had osteoporosis. I have to note that Osteodensitometry was performed in the beginning of this year, so a mean period of eighty months Between PTX and bone density measuring. (THP: total hip prothesis) To try to understand more about bone density, we compared the two groups PTX and Hyperparathyroidism patients who didn’t undergone PTX. We found that mean T score of the PTX group is quite higher than mean Tscore in the group without PTX, but this difference may be important clinically but it is not statistically significant. After a total mean follow up of eighty-nine months, fortunately no patients died. Here I wanted to share with you some unexpected progression. Mainly for the patient one who had first relapse at sixteen months, he had his second PTX that showed simple hyperplasia. But unfortunately, at 78 months, he had another relapse resistant to calcimimetics. His third PTX showed malignancy and he is now preparing treatment with chemotherapy and X ray therapy. Patient 3 as well had a rare complication, she had recurrence nine months after her selective PTX. This time her technetium scan showed an ectopic mediastinal parathyroid and she went through sternotomy. She developed suddenly many years after surgery a post sternotomy pain syndrome and felt like a coronary syndrome point to point. It tooked months and various explorations before we found diagnosis and treated effectively with amytriptiline We didn’t forget to take a look at the operative site and bring attention to scars complications. We found a skin fibrosis with retractile scar in patient one, responsible of a voice distortion. In patient eight, skin adherence and in patient nine a Keloid scar responsible of itching and stinging Almost ten percent of hyperparathyroidism patients will eventually require PTX. There is a specific type of effective surgeries like: Subtotal, total without auto implantation and total with auto implantation of parathyroid cells. However, other studies described the additional morbidity after procedure. Clinical outcomes were described essentially by the high hospitalization rate within the first year. Meanwhile, it was demonstrated that both fracture risk and mortality were reduced. So, it’s true that PTX is the treatment of choice in cases with severe hyperparathyroidism, but don’t forget the significant risk of additional morbidity and think about improving post-op care to prevent complications. Thank you for your attention