In recent decades, the percentage of patients with chronic renal failure requiring parathyroidectomy has declined as medical management has improved.5 Medical management of secondary hyperparathyroidism includes dietary phosphorus restriction, phosphorus-binding medications, calcitriol, and calcimimetics (cinacalcet). However, secondary hyperparathyroidism sometimes persists despite these interventions. Indications for surgery include failure of medical management, calciphylaxis, parathyroid hormone level greater than 800 pg/mL, hyperphosphatemia, hypercalcemia, hypercalciuria, osteoporosis, and significant symptoms such as pruritus, pathologic bone fracture, and bone pain.6 Demeure et al7 have argued that patients with secondary hyperparathyroidism are more likely to benefit from parathyroid surgery when they have bone pain, malaise, pruritus, calciphylaxis, or if parathyroid hormone levels are highly elevated (greater than 10 times the reference value). The options for parathyroidectomy in these patients include subtotal (3.5 gland) parathyroidectomy and total (4 gland) parathyroidectomy with autotransplantation. Parathyroid tissue can also be cryopreserved at the time of surgery and autotransplanted later if needed.