Background: Hypertension (HTN) is an extremely pervasive condition that affects a large percentage kidney transplant (KTX) candidates and is a risk factor for cardiovascular complications after anesthesia and surgery. Ideally, patients with severe HTN should be controlled long before surgery; however, due to the urgent nature of KTX only rapid-acting agents are an option. The importance of severe HTN in the KTX patient is not well defined. Methods: A single-center retrospective cohort study of adult KTX recipients between October 1, 2009 through December 31, 2012 was performed to examine perioperative outcomes between patients with and without severe HTN upon arrival to the pre-operative holding area, defined as systolic blood pressure >180 and/or diastolic blood pressures > 105 mmHg. Minimum follow- up was 30 days. Patient and donor demographics, nadir serum creatinine, delayed graft function (DGF); lengths of hospital stay and patient/graft survival were assessed. Continuous variables were compared by two sample Student t tests and categorical variables with Chi-square. A p-value less than 0.05 were considered significant. Results: A total of 209 patients were included; 111 patients had preoperative severe HTN ( Group 1) and 98 patients did not(Group 2). Those with severe hypertension were somewhat older (p=0.07);however, the groups were similar in terms of recipient and donor gender, race, obesity, and recipient diabetes mellitus, cold ischemia time, induction, previous kidney transplant and hepatitis C. No patients developed hypertensive crisis, intracranial hemorrhage, or life treating ventricular arrhythmias. There was no statistical significant difference between the two groups in terms of nadir creatinine >1.7( 13.9 vs 17.5%, G1 vs G2, p=0.48) and length of stay >7 days(37.8 vs 35.7 %, G1 vs G2, p=0.76); however the incidence of delayed graft function (DGF) was somewhat lower in those with severe hypertension( 52.3 vs 63.3 %, P=0.10).30-day patient survival was similar in 2 groups (both 99%), one patient died in each group, one from sepsis (no HTN) and the other with unclear cause (HTN). 30-day death censored graft survival was 100 % in both groups. Conclusions:Our study suggests that severe preoperative HTN should not be considered a contraindication to kidney transplantation. Rapid-acting agents that allow effective control in a matter of minutes and continuation of preoperative antihypertensive treatment throughout the perioperative period is results in acceptable outcomes.