In a randomized study subtotal parathyroidectomy (sPTX) was compared with total parathyroidectomy and autotransplantation of fresh tissue (PTX + AT) in 40 patients with severe secondary hyperparathyroidism (HPT). After surgery both groups were followed at 19 +/- 6 months (PTX + AT) and 19 +/- 7 months (sPTX) and at 43 +/- 9 months (PTX + AT) and 40 +/- 7 months (sPTX). There were 17 patients alive in each group at the time of the second follow-up. After sPTX, 2 patients required re-operation because of recurrent disease originating from the remaining parathyroid gland in the neck and another 2 patients were hypercalcemic at follow-up. After PTX + AT both serum calcium and alkaline phosphatase normalized significantly more often (p less than 0.03) than after sPTX. Re-operations were not required in this group. Radiological signs also improved significantly more after PTX + AT, as did clinical signs like pruritus (p less than 0.005) and muscle weakness (p less than 0.04). These results and the fact that in recurrent disease a re-operation at the autograft in the forearm is simpler than a re-operation in the neck, lead to the recommendation that PTX + AT should be considered as the method of choice in the surgical treatment of secondary HPT.