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

## TL;DR

Tertiary hyperparathyroidism is a complication in diabetic nephropathy that causes bone loss and cardiovascular risks, requiring better understanding and treatment strategies.

## Contribution

This paper provides a narrative review highlighting the underrecognized nature of THPT in diabetic nephropathy and identifies gaps in current management strategies.

## Key findings

- THPT leads to autonomous PTH secretion and complications like bone loss and vascular calcification.
- Parathyroid hyperplasia can persist after kidney transplantation, causing ongoing PTH elevation.
- Current treatments include calcimimetics, vitamin D analogues, and surgery, but optimal strategies remain unclear.

## 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.