A 47 year-old male patient, with a history of hypertension and end-stage renal disease since 2001 on regular hemodialysis and more recently on hemodialfiltration (HDF), developed secondary hyperparathyroidism. Despite adequate medical conservative management with phosphate binders, calcimimetics, diet, and three weekly sessions of HDF with Kt/V >1.3, he developed tertiary hyperparathyroidism with an average serum calcium of 11 mg/dl, phosphate 6 mg/dl, and serum PTH of > 2000 pg/ml. This required right sided parathyroidectomy. However, the patient has had extensive vascular calcification including non-functioning left radio-cephalic arterio-venous fistula (AVF), aortic calcification, and digital vessels calcification.