Accelerated hypertension with end stage renal failure not responsive to hemodialysis and ultrafiltration was an indication for bilateral nephrectomy in 22 patients, five of whom required the procedure as an emergency. Normotension occurred in every patient after removal of the kidneys, but hypertension returned in 12 persons after renal transplantation. Five of these required long term antihypertensive medication, and in an additional seven, some form of diuretic was necessary. There were no distinguishing features among those patients in whom post-transplant hypertension developed from those in whom it did not. In spite of severe accelerated hypertension in the patient with well documented chronic renal disease, prompt nephrectomy and renal transplantation were compatible, with an 86 per cent patient survival rate. Seventy-seven per cent of the kidneys functioned for an average of 29 months.