Although there has been much discussion regarding the etiology of hypertensive renal disease, clinical characteristics of this condition have not been thoroughly studied. The purpose of this investigation was to identify clinical correlates of hypertensive end-stage renal disease (ESRD) in a population of patients older than 50 years and to compare these clinical findings with those in a group of ESRD patients with certain known disorders (established diagnoses). Data regarding demographics, cause of ESRD, educational level, presence of diabetes mellitus, angina, myocardial infarction, and peripheral vascular disease were obtained from the Southeastern Kidney Council for patients starting renal replacement therapy between January 1, 1990, and August 1, 1996. Clinical characteristics were compared for white and black patients. Demographic variables and comorbid conditions were compared between groups with general linear regression or logistic regression contrast techniques. A logistic regression model was formed with hypertensive ESRD or established diagnoses as the outcome variable and comorbid and socioeconomic variables as the independent variables. Hypertensive ESRD was diagnosed in 24% of white and 38% of black patients, while established diagnoses were present in 17% of white and 7% of black ESRD patients. The most common established diagnoses were polycystic kidney disease, specified glomerulonephritis, and nephrolithiasis or obstruction. In a logistic regression model, white patients were found more likely to be classified as having hypertensive ESRD if they were older, suffered from angina and other forms of atherosclerosis, smoked, and were less educated. White patients with hypertensive ESRD were more than 2.4 times as likely to suffer from angina as patients with established diagnoses. For black patients, the presence of peripheral vascular disease and female gender were associated with an increased chance of being diagnosed as having hypertensive ESRD. The results of this investigation show that there is a strong association between atherosclerosis and hypertensive ESRD in older white patients. In black patients, the association between atherosclerosis and hypertensive ESRD was also present, but not as strong. The unique association of hypertensive ESRD with atherosclerosis suggests that atherosclerosis is a risk factor for chronic renal failure and that a primary renal microvascular disorder may lead to both hypertension and progressive renal insufficiency.