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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 hyperparathyroidism patients in the same unit. For the results, 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 in almost all patients and arthropathy associated with severe pruritus in 5 cases (55%). But the most dramatical sign that motivated patients themselves to accept the surgery was the occurrence of pathological bone fracture in 5 cases. We even witnessed once a femoral neck spontaneous fracture in a patient while he was simply sleeping. Concerning biological signs, we had obviously a medical therapy resistant and severe hyperparathyroidism with a mean PTH level at 1730 picogramme per milliliter, with tertiary profile in 4 patients. 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 nearly at 4 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 hyperparathyroidism, 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. So briefly and 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, because they were operated in the same unit nearly at the same time, or if it’s because of us starting to think 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. I have to say that this patient was the most well prepared before the surgery. Patient 9 however had a deep hungry bone syndrome, that lasted for almost eighteen months in spite of an energic calcium supplementation. But you will see later that surprinsgly, she had satisfying bone density. And now about bone fractures, you can see here that before PTX 6 bones fractures in total happened versus 3 only after PTX. Knowing that patient one had two relapses, we will see his exceptional evolution later, obviously, the risk of bone fractures was reduced after PTX. Concerning bone density analysis, here I put the lowest T-score measured in the three examined sites. T- score designs the difference in bone mass from the average of healthy young population. So as you can see, T scores are relatively low. And three patients had osteoporosis. I have to note that densitometry was performed in the beginning of this year, so a mean period of eighty months after PTX. 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. This difference may be important clinically but it is not statistically significant. After a total mean follow up of eighty-nine months, fortunately no patient died. Here I wanted to share with you some unexpected progression. You remember 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 that seemed like a coronary syndrome point to point. It tooked months and various explorations before we found diagnosis and treated effectively with amytriptiline. Don’t forget to take a look at the operative site and bring attention to scars complications. We found here a skin fibrosis with retractile scar in patient one, responsible of a voice distortion. In patient eight, skin adherence, incriminated in a mild dysphagia and in patient nine a Keloid scar responsible of itching and stinging. In literature, almost ten percent of hyperparathyroidism patients will eventually require PTX. In our population, thirty seven percent needed PTX. There is a specific type of effective surgeries like: Subtotal, total without auto implantation and total with auto implantation of parathyroid cells which seems to be the most effective procedure. Other studies described the additional morbidity after procedure, by the high hospitalization rate within the first year. Meanwhile, it was also demonstrated that both fracture risk and mortality were reduced, as it was shown in our study. 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.