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Renal hyperparathyroidism (HPTH) is first treated with vitamin D supplements and later parathyrodectomy is required; usually total removal of the four glands with self-transplantation and rarely partial resection is performed. We introduce a case of end-stage renal disease (ESRD) with very high parathormone (PTH) levels long-time after total parathyroidectomy without autoimplant, lacking the evidence of anatomical parathyroid presence. A 59-year-old female with ESRD since the age of 38 and hemodyalisis performed until the present day. The vitamin D supplementation was not adequate thus 8 years ago PTH was found increased (of 2070 pg/mL, normal: 15-65pg/mL), requiring surgery (total parathyroidectomy). Patient experienced low PTH values immediately after surgery. Further vitamin D and calcium supplements were offered and the values of total calcium remained low-normal while PTH assays were no longer done until recently. Currently, an elevated PTH of 1622 pg/mL with normal total calcium and severe vitamin D deficiency was found confirming once again renal HPTH. The imagistic tests did not reveal suggestive parathyroid masses at cervical and mediastinal computer tomography, both by using 99mTc PERTECHNETATE and SESTAMIBI parathyroid scintigraphy. Anterior cervical ultrasound suggested two right remnants of 4 mm, probably parathyroids. The best treatment for this moment is the adequate correction of vitamin D deficiency so daily oral vitamin D3 1000 UI, calcitriol 0.75 µg, and calcium carbonate 1500 mg were started. Three months later PTH decreased at 900pg/mL. If PTH might have a good response to the medication, surgery may be delayed. Moreover, the lack of adequate parathyroid masses identification will increase the surgical approach difficulty requiring intra-operatory localisation on a patient already associating multiple comorbidities. [ABSTRACT FROM AUTHOR]