Hypertension typically worsens with declining renal function, and is an almost universal feature of end-stage renal disease. Treating hypertension clearly reduces the likelihood of cardiovascular disease in nonrenal populations, with greater absolute benefit in those who have greater severity of underlying cardiovascular disease. Patients with chronic renal diseases are at enormous cardiovascular risk. Although our approach to hypertension in patients with early renal insufficiency has become more aggressive, the rationale has switched over the past decade from cardiovascular risk reduction to slowing the loss of renal function. Reliance on observational studies, especially using mortality as the outcome, has not allowed a consistent, rational approach to the treatment of hypertension in dialysis patients. (C) 2000 Lippincott Williams and Wilkins.