2. Department of Nephrology- Ain Shams University, Cairo, Egypt
Effect of total parathyroidectomy with and without autoimplantation in prevalent hemodialysis patients
Department of Nephrology- Ain Shams University, Cairo, Egypt
Sahar Shawky
Amr Mohab
Haitham Ezzat

3. Secondary hyperparathyroidism (SHPT) is common in chronic kidney disease. Despite the initiation of new therapeutic agents, several patients will require parathyroidectomy (PTX).
There are three options for the surgical treatment of SHPT: subtotal PTX , total PTX with autotransplantation (TPTX+AT), and total PTX without autotransplantation (TPTX). APSN 15 ; 441–447, 2009.

4. Aim of the study
The aim of the present study was to compare total parathyroidectomy with autotransplantation (TPTX + AT) versus total parathyroidectomy without autotransplantation (TPTX) for secondary hyperparathyroidism in prevalent hemodialysis patients with respect to long-term outcomes.

5. Patients and methods
This is a retrospective study which included 40 ESRD patients on regular HDx thrice weekly (18 men and 22 women) who underwent parathyroidectomy (PTX); with secondary hyperparathyroidism and PTH was above 800 pg/ml after failure of medical treatment (alfacalcidol and cinacalcet) for at least 6 months.
(Group I)
20 patients underwent total (PTX) with autoimplantation (median age 49 years; range years; median dialysis duration before PTX :9 years; range 5–15 years) .
(Group II)
20 patients underwent total (PTX) without autoimplantation (median age 46 years; range years; median dialysis duration before PTX :6 years; range 2–13 years).

6. Preoperative Stage:.
All patients had the following laboratory tests: iPTH, Serum Calcium, phosphorus, albumin, Alkaline Phosphatase, CBC.
Lumbosacral plain x-ray.

7. Operative stage: Postoperative stage:
All patients underwent surgery in the form of bilateral neck exploration with total parathyroidectomy without autoimplantation or total parathyroidectomy with autoimplantation of half of a gland in sternocleidomastoid or forearm.
Postoperative stage:
All patient had oral tablets, containing Calcium Carbonate, active Vitamin D (alphacalcidol) 1ug once daily.
All patients had postoperative iPTH assessment, daily serum Ca assessment till discharge.
(IV) Calcium Gluconate was administered in cases of symptomatic hypocalcaemia, or asymptomatic severe hypocalcaemia defined as serum Calcium below 6 mg/dl.
The presence of bony symptoms at the most recent clinic appointment was recorded using a verbal scale consisting of four options (resolved, improved, unchanged, or unknown).

8. No statistically significant difference between the two groups regarding gender and age
Results
Age (years)
Groups
T-Test
Group I
Group II
P-value
Range
24.000 -
60.000
25.000
64.000
0.246
Mean ±SD
49.350
8.343
46.095
9.300
Gender
Groups
Chi- Square
Group I (NO= 20)
Group II (NO=20)
Total (NO= 40) N %
P- value
Female 11
55.00 22
1.000
Male 9
45.00 18
Total 20
100.00 40

9. Duration of dialysis (years)
There was a highly statistically significant difference between both groups regarding dialysis duration
Duration of dialysis (years)
Groups
T-Test
Group I
Group II
P-value
Range
5.000 -
15.000
2.000
13.000
0.006*
Mean ±SD
9.550
3.395
6.714
2.831

10. Comparison between the two studied groups according to bone aches
Chi-Square
Group I
Group II
Total N %
P-value
Resolved 2
10.00 3
15.00 5
12.50
0.820
Improved 11
55.00 12
60.00 23
57.50
Unchanged. 4
20.00 6
Unknown 20
100.00 40

11. Corrected Ca (mg/dl) Pre Post
There was a statistically significant difference between the two groups according to postoperative s.Ca (p = 0.016), while there was no statistically significant difference between the two groups according to pre-operative s.Ca
Corrected Ca (mg/dl)
Difference
Paired
T-test
Pre
Post
Mean SD
P-value
Group I
Range
8.5 -
11.5
6.5
2.145
1.178
<0.001*
Mean±SD
9.800
0.953
7.655
0.526
Group II
11.6
5.8
8.3
2.620
0.631
9.770
0.971
7.150
0.723
0.922
0.016*

12. Duration of s.Ca normalization (days)
There was a statistically significant difference between the two groups according to duration of Ca normalization
Groups
Duration of s.Ca normalization (days)
Mann- Whitney Test
Range
Median
Interquartile Range
Mean Rank
P-value
Group I
5.000 -
30.000
12.000
6.000
17.100
0.041*
Group II
7.000
60.000
14.000
13.000
24.714

13. Phosphorus (mg/dl) Pre Post
In case of comparison between pre-operative and post-operative phosphorus level in both groups there are no statistically significant difference between them (p = 0.165) and (p = 0.219) respectively. There is also highly statistically significant difference when comparing pre-operative and postoperative phosphorus levels throughout both groups (p = <0.001 in both of them)
Phosphorus (mg/dl)
Difference
Paired T-test
Pre
Post
Mean SD
P- value
Group I
Range
5.20 -
9.60
3.90
5.80
1.985
0.66 4
<0.001 *
Mean±S D
6.69
1.09
4.71
0.56
Group II
3.50
10.4 0
3.30
6.50
2.405
1.19 4
7.41
1.97
5.00
0.89
T-test
P-value
0.165
0.219

14. There was no statistically significant difference between the two groups regarding ALP
ALP(U/L)
Groups
T-Test
Group I
Group II
P-value
Range -
0.168
Mean ±SD

15. There is no statistically significant difference when comparing the plain x-ray spine throughout both groups (p = 0.427).

16. Pre-operative PTH :There was highly statistically significant difference between the two groups according to iPTH levels 21 20
N =
Group II
Group I
PTH level (pg/ml)
4000
3000
2000
1000
Groups
iPTH level (pg/ml)
Mann- Whitney Test
Range
Median
Interquartil e Range
Mean Rank
P-value
Group I -
14.650
0.001*
Group II
27.048

17. Follow up of iPTH till a year after parathyroidectomy in group I: Comparison of pre-operative iPTH values with the Post operative iPTH, iPTH after 1 month, iPTH after 3 months, iPTH after 6 months and iPTH after 1 year showed a highly statistical significance (p = <0.001)
iPTH level 
Group I
Friedman Test
Range
Median
Interquartile Range
Mean Rank X2
P-value
iPTH level (pg/l) - 6
46.28
<0.001*
Post operative
8.500
87.500
2.35
After 1 month
11.000
2.95
After 3 months
10.000
85.500
3.3
After 6 months
12.400
84.500
3.25
After 1 year
14.000
79.000
3.15

18. Follow up of iPTH till a year after parathyroidectomy in group II comparison of pre-operative iPTH with the Post operative iPTH, iPTH after 1 month, iPTH after 3 months, iPTH after 6 months and iPTH after 1 year showed a highly statistical significance (p = <0.001)
iPTH level 
Group II
Friedman Test
Range
Median
Interquartile Range
Mean Rank X2
P-value
iPTH level (pg/l) - 6
80.34
<0.001
Post operative
3.000
40.500
8.500
10.650
1.55
After 1 month
48.000
12.400
8.450
2.1
After 3 month
4.200
45.300
13.600
13.650
2.85
After 6 month
4.600
87.000
16.400
31.650
3.75
After 1 year
24.000
57.300
4.75

19. Within group II, nine patients (45%) had measurable post-operative iPTH levels within the normal range, and 11 patients (55%) actually had iPTH levels below the normal range. At the end of the follow-up time (12 months), we saw recurrent sHPT, in 4 patients (20%) .
In group I, 5 patients (25%) had measurable post-operative iPTH levels within the normal range, and 10 patients (50%) had iPTH levels above the upper limit of the normal range thus this is could be considered Persistent sHPT but 4 patients only (20%) showed rise of the PTH levels after 6 months of follow up (recurrence). 1 patient had iPTH level below the normal range.

20. Conclusion
Total parathyroidectomy with autotransplantation, and total parathyroidectomy without implantation produced similar results when considering the regression of osteodystrophy symptoms e.g bone aches.
As one could anticipate, group II showed increased incidence of hypoparathyroidism (11 patients, 55%) while group I showed persistence (9 patients 45% ) and recurrence (4 patients, 20% ).

21. THANK YOU