Tertiary hyperparathyroidism (t-HPT) is a complex disorder, typically referring to approximately 5% of patients whose parathyroid secretion fails to normalize within 1 year after renal transplant. Correction of hypercalcemia is important to avoid urolithiasis, bone disease, cardiovascular disease, or impaired renal function. In particular, the osteodystrophy associated with chronic kidney disease is exacerbated by immunosuppressive agents. The standard surgical approach for t-HPT is either subtotal parathyroidectomy or total parathyroidectomy with autotransplantation. There are multiple conflicting reports as to the frequency of single- vs multiple-gland involvement and the risks or benefits of routine subtotal parathyroidectomy vs a more selective approach. Associated variables include the adequacy and completeness of the parathyroid resection, the size of the parathyroid remnant, possible implantation of cells from the cut surface of a parathyroid gland, eventual hyperfunction of supernumerary parathyroid glands, the frequency of the transplanted kidney failing, and the limited value of preoperative parathyroid localization or intraoperative parathyroid hormone monitoring.