Hypertension is highly prevalent in pediatric patients with end-stage renal disease (ESRD). Ambulatory blood pressure monitoring (ABPM) has been used to characterize the altered circadian blood pressure patterns in ESRD in order to improve our understanding of the blood pressure dysregulation that occurs in these children. In children receiving chronic hemodialysis, 24-h blood pressure load elevation and a high prevalence of non-dipping are reported for both systolic blood pressure (SBP) and diastolic blood pressure ((DBP). When comparing casual and ABPM measurements for diagnosing hypertension, ABPM reclassified approximately one third of patients from normotensive to hypertensive and from hypertensive to normotensive. ABPM has also been used to confirm experimentally that interdialytic weight gain is positively associated with increases in interdialytic blood pressure. In children who have undergone renal transplantation, 24-h blood pressure load elevation and non-dipping are also highly prevalent. A non-dipping pattern in transplant patients may be indicative of underlying renal parenchymal, renovascular disease or effect of medications. The prevalence of left ventricular hypertrophy (LVH) in pediatric patients after transplantation is approximately 20%, and left ventricular mass index (LVMI) is correlated with 24-h, daytime, and night-time ambulatory blood pressure. Since ESRD is a lifetime disease, addressing the high prevalence of hypertension and altered circadian blood pressure patterns in childhood may help prevent cardiovascular morbidity and mortality in early adulthood. Further studies are therefore needed to establish the utility of ABPM for the management of hypertension and prevention of end-organ injury in children with ESRD.