[Evolution of surgical strategies for secondary hyperparathyroidism]

Secondary hyperparathyroidism (SHPT) is an important component of chronic kidney disease-mineral and bone disorder (CKD-MBD). It may be accompanied by bone pain, pruritus, abnormalities in bone metabolism, and vascular and soft-tissue calcifications, thereby increasing the disease burden in patients with end-stage kidney disease. Historically, surgical management of SHPT was mainly based on persistently elevated parathyroid hormone (PTH) levels and patients' responses to medical therapy, gradually establishing a management strategy centered on PTH control. This strategy has played an important role in selecting candidates for surgery and facilitating multidisciplinary communication. With the evolution of the CKD-MBD concept and accumulating evidence on clinical outcomes, the goals of surgical treatment have gradually expanded from merely lowering PTH levels to improving bone metabolism, relieving symptoms, controlling CKD-MBD-related target-organ damage, and improving long-term outcomes. Based on current guidelines, expert consensus, and clinical studies, this review discusses the historical basis and limitations of PTH threshold-based strategies and examines the evolution of surgical management for SHPT, with particular emphasis on the timing of surgical evaluation, surgical indications, choice of surgical procedure, perioperative management, postoperative follow-up, and future directions for optimization.