Obesity-related hypertension in pediatric patients is becoming more prevalent around the world as a consequence of the childhood obesity epidemic. Hypertension and the metabolic abnormalities associated with obesity will significantly increase the health risks for these children as they grow into adulthood. The pathophysiology of obesity-related hypertension is complex, and multiple potential mechanisms likely contribute to the development of higher blood pressure in obese children. These include hyperinsulinemia, activation of the renin-angiotensin-aldosterone system, stimulation of the sympathetic nervous system, abnormalities in adipokines such as leptin, direct effects of perinephric fat on the renal parenchyma, and cytokines acting at the vascular endothelial level. As in any child with elevated blood pressure, diagnostic evaluation should focus on confirmation of hypertension, determine if an underlying cause can be identified and whether hypertensive target organ damage is present. Therapy should begin with lifestyle modifications, but will often need to include one or more antihypertensive medications.