*Purpose: Hyperparathyroidism is prominent in patients with chronic kidney disease with reduced renal function and has been observed after kidney transplantation. There is a debate about which treatment is better for cases where hyperparathyroidism persists after kidney transplantation.

*Methods: This retrospective study included 83 patients who underwent kidney transplantation with tertiary hyperparathyroidism between 2000 and 2018 in a single tertiary center. Sixty-four patients underwent parathyroidectomy and 19 patients were treated with cinacalcet after transplantation (Figure 1). We compared biochemical parameters and clinical outcomes between the two groups.

*Results: Serum calcium and PTH levels improved in both the parathyroidectomy group and cinacalcet group. One year after treatment, parathyroidectomy resulted in a lower mean serum calcium level (9.7 ± 0.7 mg/dL) than cinacalcet (10.5 ± 0.7 mg/dL) (P = 0.001). For the serum PTH, the parathyroidectomy group showed a significantly lower PTH level than the cinacalcet group at 6 months (129.1 ± 80.3 vs. 219.2 ± 92.5 pg/mL) (P = 0.002) and 1 year (118.8 ± 75.5 vs. 250.6 ± 94.5 pg/mL) (P < 0.001). There was no statistically significant difference in the incidence of kidney transplant rejection, graft failure, cardiovascular events, fracture risk, or bone mineral density changes between the two groups.

*Conclusions: Parathyroidectomy seems to lower PTH and calcium levels effectively in tertiary hyperparathyroidism. However, creatinine level and allograft rejection should be monitored closely.

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