Secondary hyperparathyroidism (SHPT) is a significant and challenging complication of chronic kidney disease (CKD), characterized by excessive secretion of parathyroid hormone (PTH) due to prolonged disturbances in calcium, phosphate, and vitamin D metabolism. Despite advances in medical management, including calcimimetics and active vitamin D analogs, a subset of patients develops refractory SHPT that requires surgical intervention. Total parathyroidectomy with auto-transplantation (TPTX-AT) has emerged as a definitive treatment modality for severe cases of SHPT, particularly when conservative measures fail to achieve therapeutic targets or when patients experience debilitating symptoms. This review explores the role of TPTX-AT in the management of SHPT, emphasizing its procedural aspects, patient selection criteria, and perioperative considerations. The technique involves the complete removal of hyperfunctioning parathyroid tissue with the reimplantation of a portion of the gland, typically in the forearm or other accessible site, to maintain minimal parathyroid function and prevent permanent hypoparathyroidism. We analyze outcomes from recent studies, focusing on the resolution of biochemical abnormalities, improvement in clinical symptoms, and long-term quality-of-life benefits. Additionally, we address potential complications, such as graft failure, recurrence of SHPT, and postoperative hypocalcemia, alongside strategies for their prevention and management. Through a comprehensive synthesis of clinical evidence and guidelines, this review highlights the importance of a multidisciplinary approach in optimizing surgical outcomes. It underscores the role of TPTX-AT not only in controlling SHPT but also in reducing associated cardiovascular and skeletal complications, thereby improving overall patient prognosis. Future directions in research and practice, including innovations in surgical techniques and monitoring of auto-transplant functionality, are also discussed to enhance the therapeutic landscape for patients with refractory SHPT