Several metabolic derangements, including enhanced protein catabolism, have been suggested to be associated with increased circulating parathyroid hormone (PTH) in patients with secondary hyperparathyroidism (HPT). Such conditions, therefore, might lead to an increase in energy expenditure. The present study examined by indirect calorimetry the resting energy expenditure (REE) of 15 hemodialysis patients who have severe HPT (PTH = 1457 +/- 676 pg/ml) and were pair-matched for age and gender to 15 hemodialysis patients with mild to moderate HPT (PTH = 247 +/- 196 pg/ml). Both groups were also pair-matched for age and gender to a group of 15 healthy adult subjects (control). In six patients from the severe HPT group submitted to total parathyroidectomy, REE was determined 6 mo after the surgery. The groups were not different regarding lean body mass (LBM) measured by bioelectric impedance, serum C-reactive protein, and bicarbonate. Thyroid-stimulating hormone was within the normal range in all groups. Nonadjusted REE was significantly higher in the severe HPT group (1674 +/- 337 kcal/d) compared with patients with mild to moderate HPT (1388 +/- 229 kcal/d; P < 0.05). Both groups did not differ from the control group (1468 +/- 323 kcal/d). When adjustment of REE for LBM was performed using the multiple regression analysis, patients with mild to moderate HPT and control subjects had significantly lower REE (-231 and -262 kcal, respectively) than that of the severe HPT group. Considering all patients together, nonadjusted REE correlated directly with LBM (r = 0.61; P < 0.01). PTH correlated strongly with LBM in the severe HPT group (r = -0.82; P < 0.01). In the multiple linear regression analysis, only LBM and PTH were independent determinants of REE (n = 30; R(2) = 0.47). REE decreased significantly in the six patients who were evaluated 6 mo after parathyroidectomy (from 1617 +/- 339 to 1226 +/- 253; P = 0.02). These results demonstrate that hemodialysis patients with severe HPT have increased REE that might be reduced after parathyroidectomy.