The effects of hemodialysis, bilateral nephrectomy, and renal homotransplantation were evaluated in 12 patients with renal failure due to primary malignant hypertension. The blood pressure was difficult to control with hemodialysis, moderately high doses of antihypertensives, and dietary restriction. Bilateral nephrectomy resulted in significant reduction of diastolic blood pressure and reduction in the number and quantities of antihypertensive medication. Fourteen renal homografts were performed. Patient survival and transplant function compare favorably with other patients transplanted by us and those reported to the Human Transplant Registry. In the posttransplant period, hypertension was a problem in only two patients. The mean diastolic blood pressure was similar to that achieved by bilateral nephrectomy. Renal transplantation is an acceptable therapy for patients who have been treated by bilateral nephrectomy for malignant nephrosclerosis.