Less-than-subtotal parathyroidectomy increases the risk of persistent/recurrent hyperparathyroidism after parathyroidectomy in tertiary hyperparathyroidism after renal transplantation. 
The optimal surgical approach for tertiary hyperparathyroidism (HPT) after kidney transplantation is unknown.  Existing studies are limited by small sample size, lack of adjustment for kidney function, and no long-term follow-up.  We retrospectively analyzed 74 patients with tertiary HPT who underwent parathyroidectomy at two centers since 1978.  Persistent HPT was defined as parathyroid hormone (PTH) concentrations in excess of the K/DOQI target range for the corresponding estimated creatinine clearance (eCrCl).  Seventy-four patients had 83 operations (72 subtotal and 11 less-than-subtotal parathyroidectomies).  Mean follow-up time was 5.4 +/- 4.7 years.  Calcium concentrations decreased significantly after parathyroidectomy (2.83 vs 2.28 mmol/L, P < 0.001), as did eCrCl (54.5 vs 44.9 mL/min, P < 0.001) and PTH (382 vs 132 pg/mL, P < 0.001).  In the multivariable regression analysis, only the type of operation and postoperative eCrCl were significantly correlated with PTH at follow-up.  A limited parathyroidectomy was associated with a fivefold increase in risk of persistent or recurrent hyperparathyroidism.  The use of limited parathyroidectomy for tertiary HPT after kidney transplantation has a higher risk of persistent/recurrent HPT.  Subtotal parathyroidectomy is recommended for patients with tertiary HPT.