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September 10, 2025Open Access

Tertiary Hyperparathyroidism in Diabetic Nephropathy: An Underrecognized Complication – A Narrative Review

Key Points

Tertiary hyperparathyroidism can lead to sustained parathyroid hormone elevation, bone loss, and cardiovascular complications.
Effective management often includes medications like calcimimetics and vitamin D analogues, but optimal timing for treatment remains unclear.
Surgical intervention through parathyroidectomy can restore balance, but knowledge gaps exist in treatment consensus.
This review emphasizes the complexity of managing tertiary hyperparathyroidism, suggesting ongoing research is essential.

Abstract

Tertiary hyperparathyroidism (THPT) arises in patients with chronic kidney disease (CKD) as a consequence of prolonged secondary hyperparathyroidism and is marked by autonomous parathyroid hormone (PTH) secretion. In some cases, parathyroid hyperplasia persists even after successful renal transplantation, resulting in sustained PTH elevation and hypercalcaemia. These alterations contribute to bone loss, vascular calcification, and increased cardiovascular risk. Management includes medical therapy with calcimimetics or vitamin D analogues and surgical intervention via parathyroidectomy. However, optimal timing and treatment strategy remain uncertain. This review examines the pathophysiology, clinical manifestations, and current management paradigms of THPT, with an emphasis on areas that require further research and consensus.

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