The problem of diagnosis and choice of treatment methods for tertiary hyperparathyroidism in modern clinical practice. Literature review

In current literature, tertiary hyperparathyroidism (THPT) is considered a serious complication that most often occurs in patients with stage V chronic kidney disease on long-term renal replacement therapy (hemodialysis), as well as in kidney transplant recipients after a long period of secondary hyperparathyroidism. Objective To analyze contemporary literature data on the pathogenesis, diagnosis, and surgical treatment of tertiary hyperparathyroidism. Materials and methods. This study presents an analytical review of recent publications from international scientific databases — PubMed, Scopus, and Web of Science — focusing on the pathogenesis, diagnosis, and surgical management of tertiary hyperparathyroidism published between 2020 and 2025. Results. A review of recent literature indicates that THPT develops as a result of long-standing parathyroid gland hyperplasia, leading to autonomous parathyroid hormone (PTH) secretion and persistent hypercalcemia. The key diagnostic features include the coexistence of hypercalcemia with markedly elevated PTH levels, along with imaging evidence of nodular parathyroid hyperplasia identified by ultrasonography and/or 99mTc-MIBI scintigraphy. Currently, surgical parathyroidectomy—either subtotal or total with autotransplantation—remains the most effective treatment option, achieving normalization of PTH concentrations and restoration of calcium–phosphate homeostasis in most patients. Conclusions. Timely recognition of the transition from secondary to tertiary hyperparathyroidism—characterized by extremely elevated PTH levels, the onset of hypercalcemia, and nodular parathyroid hyperplasia confirmed by ultrasound or scintigraphy—serves as a clear indication for surgical intervention, since only parathyroidectomy can definitively eliminate THPT. A comprehensive approach integrating the assessment of clinical manifestations, laboratory dynamics, and imaging findings enables accurate diagnosis and optimal surgical planning. Surgical treatment of THPT is highly effective: in more than 90% of cases, normalization of PTH levels and calcium–phosphate balance is achieved, accompanied by symptom regression, improved quality of life, and a reduction in cardiovascular complications. In most cases, the procedure of choice is subtotal parathyroidectomy involving the removal of three or more glands with mandatory identification of all four; if subtotal resection is not feasible (due to ectopic glands, reoperation, or other factors), total parathyroidectomy with autotransplantation of parathyroid tissue is performed. Adherence to modern principles of diagnosis and management of THPT substantially improves disease outcomes, enhances post-transplant kidney function, and contributes to a more favorable long-term prognosis for this group of patients.