BACKGROUND Renal transplant patients are unique in that bone changes occur on a background of pre-existing chronic kidney disease-mineral bone disorder. In a few cases, there is overt hyperparathyroidism manifested by hypercalcaemia. Traditionally, if severe or persistent, this is treated by parathyroidectomy. At our unit, the default surgical operation is total parathyroidectomy without autotransplantation. METHODS Patient charts for the last three decades were reviewed retrospectively. Twenty-six subjects with functioning renal transplants who underwent parathyroidectomy had biochemistry and clinical information for at least 6 months pre- and post-surgery. The criteria for parathyroidectomy were persistent hypercalcaemia (>2.75 mmol/L) and/or clinical problems (e.g. kidney stones). A 5-year follow-up was available for all 26 subjects and a 9-year follow-up for 20 patients. RESULTS After surgery, patients were supplemented with 1-α-calcidol. The median preoperative calcium level was 3.10 mmol/L. One month postoperatively, this fell to 2.41 mmol/L. Normocalcaemia was maintained at 5 years (2.40 mmol/L) and at 9 years (2.39 mmol/L), with a calcium-phosphate product of 3.0 mmol(2)/L(2) and median parathyroid hormone level of 12 pg/mL. CONCLUSIONS Total parathyroidectomy without autotransplantation in renal transplant patients appears to be protective against persistent and recurrent disease. This is the largest series with the longest follow-up available in the literature of this specific patient population.