BACKGROUND A subset of patients who are being maintained on dialysis for end-stage renal disease develop severely symptomatic secondary hyperparathyroidism that cannot be controlled medically. The relative merits of two alternative surgical approaches--subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation--have not been clearly elucidated. METHODS The records of 77 patients who had renal failure and underwent parathyroid surgery between 1982 and 1993 were retrospectively reviewed. RESULTS Fifty-three patients (69%) underwent subtotal parathyroidectomy and 24 (31%) underwent total resection with auto-transplantation into forearm musculature. The incidences of postoperative hypocalcemia and tetany were similar in both groups, as was the recurrence rate (7%) of clinically significant hyperparathyroidism. CONCLUSIONS Subtotal parathyroidectomy can be performed without mortality or morbidity and provides good control of hyperparathyroidism secondary to chronic renal failure. Total parathyroidectomy with autotransplantation offers no additional advantage in this difficult patient population. Most patients will require postoperative intravenous calcium replacement. We observed a significant incidence of continued hyperparathyroidism following successful renal transplantation.