Hypertension is common and poorly controlled in dialysis patients. Despite its prevalence, accurate diagnosis and treatment remain challenging. Blood pressure measurement is crucial. Traditional methods often miss the severity of hypertension. The diagnosis of hypertension in dialysis patients is best made by measurements outside the dialysis unit such as in home or 44-h interdialytic ambulatory BP monitoring. BP increases approximately linearly over the first 2 days following dialysis and then tends to plateau. Measurements at home after the midweek dialysis taken twice daily for 4 days are sufficient for clinical decision-making in the management of hypertension in hemodialysis patients. Although the exact targets of BP remain unknown in dialysis patients, home BP range of 120–140 mmHg systolic appears reasonable. If home or interdialytic ambulatory blood pressure recordings are not available, then predialysis and postdialysis BP recordings in isolation should not be used to made diagnostic decisions regarding hypertension; median intradialytic BP recordings are more suitable. Median intradialytic systolic BP during a midweek dialysis of 140 mmHg or more is sufficient to make a diagnosis of hypertension when out-of-dialysis unit measurements are not available. Lowering blood pressure is essential. While correlation doesn’t equal causation, studies suggest that reducing blood pressure can lower the risk of cardiovascular events. Treatment focuses on volume reduction. Dietary sodium restriction, dialysate sodium adjustment, and aggressive dry weight management are key. Drug therapy often involves beta-blockers, followed by long-acting dihydropyridines such as amlodipine and felodipine, and then ACE inhibitors or angiotensin receptor blockers. Spironolactone requires further study. We do not recommend thiazide or loop diuretics.