Background <p>Serum zinc levels decline with chronic kidney disease (CKD) progression, and zinc deficiency has been linked to impaired urinary sodium excretion and hypertension. However, its clinical impact on hypertension management in end-stage kidney disease remains unclear. This study investigated the association between serum zinc deficiency and antihypertensive treatment intensity in patients with stage 5 CKD initiating dialysis.</p> Methods <p>In this single-center cross-sectional study, 175 adults initiating hemodialysis or peritoneal dialysis between November 2021 and December 2024 were included. Serum zinc levels were measured at dialysis initiation, and zinc deficiency was defined as &lt; 60&#xa0;μg/dL. Logistic and ordered logistic regression analyses adjusted for demographic and hypertension-related factors were conducted to evaluate factors associated with zinc deficiency and its relationship with the number of prescribed antihypertensive agents.</p> Results <p>Zinc deficiency was present in 59.4% of patients. Patients with zinc deficiency required more antihypertensive agents than those without deficiency. Zinc deficiency was significantly associated with antihypertensive agent number in univariate analyses and remained an independent factor in multivariate logistic regression (adjusted OR 1.6, 95% CI 1.0–2.4). Ordered logistic regression further demonstrated an independent association between zinc deficiency and greater antihypertensive treatment intensity after adjustment for age, sex, and hypertension-related risk factors (adjusted OR 2.4, 95% CI 1.1–5.3).</p> Conclusion <p>Zinc deficiency was independently associated with more intensive antihypertensive therapy. These findings suggest that zinc deficiency may contribute to antihypertensive treatment intensity in advanced CKD. Assessment of zinc status may offer an underrecognized opportunity to improve blood pressure control in this population.</p>