Parathyroidectomy is commonly required in patients with hyperparathyroidism secondary to end stage renal failure. Most descriptions of parathyroid anatomy are based on studies of normal glands. The details of parathyroid anatomy in 60 consecutive patients undergoing total parathyroidectomy for hyperparathyroidism secondary to renal failure are presented. Comparisons are made with the anatomical locations in series of normal glands. Based on these findings a strategy is proposed for the successful identification of all the parathyroid glands in patients undergoing parathyroidectomy for renal hyperparathyroidism.