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Secondary (Renal) and Tertiary Hyperparathyroidism

What is Secondary Hyperparathyroidism?

Secondary hyperparathyroidism is usually found in patients with kidney failure and involves all four parathyroid glands. The kidney problems trigger the parathyroid glands into making excess parathyroid hormone (PTH). Calcium levels are usually in the normal or low range and PTH levels can be markedly elevated. Most patients with renal failure and mildly elevated parathyroid hormone levels can be treated with medications, such as cinacalcet. When parathyroid hormone levels become extremely elevated, surgery is usually the only way to adequately control the hyperparathyroidism.

In addition to symptoms seen with primary hyperparathyroidism, other signs, symptoms and complications of secondary hyperparathyroidism can develop, including:

  • Bone deformities
  • Broken bones (fractures)
  • Swollen joints

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Severe secondary hyperparathyroidism can lead to calciphylaxis, which is a life threatening condition. Calciphylaxis can lead to soft-tissue wounds that won't heal until the hyperparathyroidism is controlled. Chronic soft tissue wounds can lead to widespread infection (sepsis) and death.

What is Tertiary Hyperparathyroidism?

Tertiary hyperparathyroidism is usually seen in patients who have undergone a kidney transplant for renal failure. Instead of the parathyroid gland function returning to normal after the kidney transplant, the parathyroid glands fail to respond to the normal signals for PTH secretion and regulation of calcium levels. In these patients, the PTH level is high and the calcium level is high.

After patients receive a kidney transplant, the parathyroid hormone levels are watched to ensure they return to normal. Usually, parathyroid hormone levels return to normal within a year. If the PTH levels do not return to normal, excess PTH can cause calcium levels to rise above normal. Patients are at the same risk to develop kidney stones, decreased kidney function, decreased bone density and other consequences of hyperparathyroidism. In cases where the PTH level has not decreased adequately after a kidney transplant, parathyroid surgery will usually be recommended.

Parathyroid Operations for Secondary and Tertiary Hyperparathyroidism

The cause for these two types of disease is related to the kidneys, or something else in the body that is not functioning properly. In general, all four parathyroid glands are affected and must be explored using the traditional four gland parathyroid exploration. A four gland exploration involves making a small incision in the lower neck and dissecting through the layers of fat and muscle that lead to the thyroid gland. The thyroid gland is then moved towards the midline of the body and the upper and lower parathyroid glands are identified on each side. Abnormally enlarged parathyroid glands are removed.

Because patients with secondary and tertiary hyperparathyroidism are more prone to have extra parathyroid glands, the tissue that lies just below the thyroid gland and above the chest is removed, as this is a common place for extra glands to be found. The wound is closed with sutures, a substance similar to super glue, and/or steri-strips.

What Can I Expect After My Operation for Secondary Hyperparathyroidism?


Parathyroid operations, regardless of the type, are very well tolerated. Pain is relatively mild, and many patients complain more about a sore throat from the breathing tube (if surgery was performed under general anesthesia) than they do about pain from their incision.

Patients with secondary hyperparathyroidism are usually kept in the hospital for 3-5 days after surgery. This is because it takes some time for the calcium level in the bloodstream to stabilize. Patients are usually placed on high doses of oral or intravenous calcium and oral Vitamin D. Patients will be dialyzed in the hospital if necessary. Dialysis can also help regulate the calcium level. Once the calcium level has stabilized and patients are not having symptoms of low calcium levels, they are discharged home.

Patients are asked to take calcium supplements in the form of CitraCal Maximum with Vitamin D while at home. The appropriate dose will be written for you and included in your discharge paperwork. OsCal is available at many drugstores and does not require a prescription. We ask all of our patients to use this brand of calcium after their operation so that we can manage your calcium level more easily and uniformly.

The pain associated with the incision is not particularly great, and is usually able to be controlled with something like Tylenol or ibuprofen, if ibuprofen is appropriate in your case. Rarely is stronger pain medication required at home, but if so it is usually only necessary for a day or two.

You may eat and drink whatever you would like after surgery. You may resume your normal daily activities as soon as you would like; however, we ask that you refrain from any strenuous physical activity, heavy lifting, or exercise until you return to the office for your postoperative visit.

You may shower 24 hours after your surgery and wash gently with soap and water over the incision. Many of you will be discharged home with steri-strips in place over the incision. You can and should wash over these, however, do not submerge them in a bathtub, hot tub, or pool. Shower water is okay to get on the incision. Allow the steri-strips to remain in place until they fall off on their own.

What Can I Expect After My Operation for Tertiary Hyperparathyroidism?

Just as with any other parathyroid surgery, an operation to repair tertiary hyperparathyroidism is very well tolerated and usually does not cause much pain afterward. Patients with tertiary hyperparathyroidism are usually kept in the hospital overnight after their operation, and are generally sent home the next day once their calcium levels are at an appropriate level for discharge.

Patients are asked to take calcium supplements in the form of CitraCal Maximum with Vitamin D while at home. The appropriate dose will be written for you and included in your discharge paperwork. OsCal is available at many drugstores and does not require a prescription. We ask all of our patients to use this brand of calcium after their operation so that we can manage your calcium level more easily and uniformly.

The pain associated with the incision is not particularly great, and is usually able to be controlled with something like Tylenol or ibuprofen. Rarely is stronger pain medication required at home, but if so it is usually only necessary for a day or two.

You may eat and drink whatever you would like after surgery. You may resume your normal daily activities as soon as you would like; however, we ask that you refrain from any strenuous physical activity, heavy lifting, or exercise until you return to the office for your postoperative visit.

You may shower 24 hours after your surgery and wash gently with soap and water over the incision. Many of you will be discharged home with steri-strips in place over the incision. You can and should wash over these, however, do not submerge them in a bathtub, hot tub, or pool. Shower water is okay to get on the incision. Allow the steri-strips to remain in place until they fall off on their own.

For appointments, please call 734.936.5818
The Priority Parathyroid Program