Severe hypocalcemia (SH) is a common and serious complication in dialysis patients with secondary hyperparathyroidism (SHPT) after parathyroidectomy (PTX). The aim is to explore the risk predictors of SH in post-PTX dialysis ESRD patients with SHPT. 129 consecutive dialysis patients with SHPT underwent PTX were retrospectively reviewed. A total of 22 clinical parameters were included in the study. SH was defined as the minimum values of serum calcium lower than 1.875 mmol/L (7.5 mg/dL) after surgery. Univariate analysis showed that pruritus, lumbar X-ray changes of renal osteodystrophy, pre- and post-operative intact parathyroid hormone (iPTH), Calcium, alkaline phosphatase, and gland mass were significantly different between SH and non-SH groups. In the multivariate logistic regression model, the pre-operative serum iPTH, calcium, and pruritus were independent risk predictors of SH. AUCs for pre-operative serum iPTH, calcium and pruritus were 0.810, 0.714 and 0.591, respectively. Patients with higher level of pre-operative serum iPTH, lower level of serum calcium and with no/mild symptoms of pruritus are at greater risk of developing SH after PTX.