Background: Patients with end stage renal disease (ESRD) have a cardiovascular mortality about 15-30 times the general population and this is reduced by about 70% with renal transplant. Dobutamine stress echocardiography (DSE) is commonly performed for preoperative cardiac evaluation before renal transplantation. Hypertensive response during DSE occurs in about 1-5% of DSE studies. However, it seems to be more frequent in patients with ESRD. But its frequency and clinical implications are not known. Methods and Results: Of the 249-consecutive adult ESRD patients undergoing DSE for pre-kidney transplant cardiac risk assessment at our dedicated clinic, 53 (21%) had a hypertensive response. Half of the patients with a hypertensive response, had stress induced segmental wall motion abnormalities, of whom only half had angiographically significant coronary artery disease by quantitative coronary angiography. The hypertensive response was not a predictor of survival. Stress induced segmental wall motion abnormalities predicted poor survival in those with a normotensive response, but not in those with a hypertensive response. The main and independent predictor of a hypertensive response was higher baseline systolic blood pressure (p< 0.0001). Conclusions: Hypertensive response to dobutamine stress is common in ESRD patients and is not a predictor of survival. Stress induced segmental wall motion abnormalities occur nearly thrice as frequently with a hypertensive response, but this is a poor predictor of angiographically significant coronary artery disease and does not predict survival.