Diagnosis and Management Gaps in Tertiary Hyperparathyroidism Following Renal Transplant

BackgroundTertiary hyperparathyroidism (3HPT) occurs when hypercalcemia and elevated parathyroid hormone (PTH) persist after renal transplantation. Our study aims to identify gaps in the diagnosis and treatment of patients with 3HPT.MethodsIn a single-center retrospective analysis, we identified renal transplant patients with 3HPT based on the history of secondary hyperparathyroidism, preserved renal allograft function, and persistent serum PTH elevations (12-88 pg/mL) during postoperative follow-up.ResultsA total of 1556 patients were biochemically diagnosed with 3HPT. Median age was 57 (IQR = 47-65). Most were male (n = 888, 61%), black (n = 801, 55%), and did not undergo parathyroidectomy (n = 1388, 95.4%). Of these, 29.4% (n = 429) of the patients were diagnosed and treated, 23.4% (n = 354) were diagnosed and not treated, and 46.2% (n = 672) remained undiagnosed. Predictive factors for diagnosis and treatment included elevated pre-kidney transplantation PTH levels ≥ 600 pg/mL, postoperative PTH levels ≥ 300 pg/mL, and elevated postoperative calcium (≥10.4 mg/dL).ConclusionMost patients with biochemical 3HPT remain undiagnosed. This highlights gaps in patient care and the need for clearer guidelines on timing for PTH assessment and surgical referral in patients with 3HPT.