Parathyroidectomy timing for persistent hyperparathyroidism in kidney transplant candidates and recipients: from secondary to tertiary disease: a literature review

Background and Objective: Secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) is a major challenge in the context of patients awaiting renal transplantation. Optimal timing of parathyroidectomy (PTX) for these patients remains controversial, particularly to prevent tertiary hyperparathyroidism (THPT) and minimize postoperative complications such as hungry bone syndrome (HBS). The aim of this study is to evaluate current evidence on optimal timing of PTX in renal transplant candidates. Methods: To review the current evidence regarding the optimal timing of PTX in patients with SHPT undergoing renal transplantation, a systematic search of PubMed/MEDLINE, Scopus, and Web of Science was performed using the following keywords: hyperparathyroidism; renal transplant; parathyroidectomy timing; secondary hyperparathyroidism; tertiary hyperparathyroidism; hungry bone syndrome; CKD-MBD; graft survival; cinacalcet; cost-effectiveness. Biochemical outcomes, graft survival, and risk of THPT were assessed. Studies in English language from 2017–2025 were included. Study selection followed PRISMA criteria. Outcomes analyzed included biochemical control, graft function, recurrence rates, and postoperative complications. Key Content and Findings: Fifteen studies met inclusion criteria, including one systematic review, two narrative reviews, three cost-effectiveness analyses, eight retrospective studies and one randomized controlled trial. Early PTX (pre-transplant or within 12–18 months post-transplant) was associated with lower rates of persistent hyperparathyroidism (HPT), better biochemical control, reduced vascular calcifications, and decreased hospitalization rates. Delayed PTX (>18–24 months post-transplant) was linked to higher rates of THPT, bone loss, nephrocalcinosis, and reduced graft function. HBS occurred more frequently in pre-transplant PTX but was manageable with structured calcium/vitamin D replacement. Conclusions: PTX remains the most effective treatment for persistent HPT in renal transplant candidates. Current evidence supports pre-transplant PTX in severe SHPT or within 12–18 months after transplant if HPT persists. A multidisciplinary approach and early biochemical surveillance are essential for optimal outcomes.