Total Parathyroidectomy With Brachialis Muscle Autotransplantation in a Renal Transplant Recipient With Tertiary Hyperparathyroidism: A Case Report.

Tertiary hyperparathyroidism (THPT) is a complication of long-standing secondary hyperparathyroidism (SHPT) in patients with end-stage renal disease (ESRD), which may persist even after renal transplantation. It is defined by autonomous, dysregulated parathyroid hormone (PTH) secretion, often refractory to pharmacologic therapy, and typically necessitating surgical intervention. We report the case of a 72-year-old renal transplant recipient with persistent THPT who underwent total parathyroidectomy (tPTX) with selective autotransplantation of parathyroid tissue into the left brachialis muscle. This approach was chosen to address ectopic glands and anatomical complexity, while facilitating postoperative monitoring and preserving superficial forearm structures for potential future dialysis access. Postoperatively, PTH normalized at 10 months (57 pg/mL) with stable calcium and renal function, confirming durable graft function and clinical remission. Total parathyroidectomy with brachialis muscle autotransplantation provides a safe, technically feasible, and functionally advantageous option for managing advanced or ectopic THPT. To our knowledge, this represents the first documented case of brachialis autotransplantation for THPT in Greece.