Objective To investigate the bone mineral density (BMD) levels and their influencing factors in patients with maintenance hemodialysis (MHD) complicated by refractory secondary hyperparathyroidism (rSHPT), and analyze the risk factors for osteoporosis (OP). Methods The study included 94 patients with maintenance hemodialysis (MHD) and refractory secondary hyperparathyroidism (rSHPT) who were treated at Gansu Provincial People's Hospital and underwent parathyroidectomy (PTX). During surgery, the size and weight of the parathyroid glands were measured. Bone mineral density (BMD) of the lumbar spine, femoral neck, and hip joint was measured using dual-energy X-ray absorptiometry (DXA). Patients were classified into three groups based on their bone mineral density (BMD): normal bone mass group, osteopenia group, and osteoporosis group. General information, laboratory test results, maximum parathyroid diameter and total weight，bone metabolic markers, and BMD were compared among these three groups. Pearson or Spearman correlation analysis was utilized to evaluate the correlations between clinical data and BMD of the lumbar spine, femoral neck, and hip joint. Univariate and multivariate logistic regression analyses were performed to assess the risk factors for osteoporosis (OP) in patients with maintenance hemodialysis (MHD) complicated by refractory secondary hyperparathyroidism (rSHPT). Results The results of the correlation analysis showed that lumbar spine BMD was negatively correlated with gender, alkaline phosphatase, PTH, blood glucose levels ，maximum parathyroid diameter, and total parathyroid weight (P< 0.05), while it was positively correlated with serum creatinine and osteocalcin levels (P<0.05). Femoral neck BMD was negatively correlated with gender, age, iPTH, blood glucose levels and total parathyroid weight (P<0.05), and positively correlated with albumin, β-CTX, and osteocalcin levels (P<0.05). Hip BMD was negatively correlated with gender, age, alkaline phosphatase, iPTH, blood glucose levels and total parathyroid weight (P<0.05), and positively correlated with albumin, serum creatinine, and osteocalcin levels (P<0.05). Using the occurrence of osteoporosis as the dependent variable, variables that showed significant correlation in the univariate logistic regression analysis, including age, gender, albumin, serum creatinine, blood glucose, iPTH, β-CTX, 25-hydroxyvitamin D ，maximum parathyroid diameter, and total parathyroid weight (all P<0.05), were included in the multivariate logistic regression analysis. The results revealed that blood glucose，iPTH, and total parathyroid weight were independent risk factors for osteoporosis in patients with maintenance hemodialysis (MHD) complicated by refractory secondary hyperparathyroidism (rSHPT) (all P<0.05). Conclusion In patients with maintenance hemodialysis (MHD) complicated by refractory secondary hyperparathyroidism (rSHPT), blood glucose，intact parathyroid hormone (iPTH), and total parathyroid weight are independent risk factors for osteoporosis