Background The strong relationship between urinary albumin excretion (UAE) and pulse pressure (PP) in cross-sectional studies suggests that pressure pulsatility may contribute to renal microvascular injury. The longitudinal relationships between UAE and the various indices of blood pressure (BP) are not well studied. We compared the associations of UAE with the longitudinal burden of PP, systolic, diastolic, and mean BP. Methods and Results UAE was measured from 24-hour urine collections in 450 community-dwelling subjects (age=57±15 years, 53% women, all with UAE<200 µg/min). For each subject, longitudinal indices of BP were estimated by dividing the area under the curve of serial measurements of BP (median=5) during 1–22 years preceding UAE measurement by the number of follow-up years. Median [interquartile range] UAE was 4.7 [3.3–7.8] µg/min in women and 5.2 [3.7–9.8] µg/min in men. In women, UAE was not related to longitudinal indices of BP. In men, in multivariable-adjusted models that included either longitudinal systolic and diastolic BP, or longitudinal PP and mean BP, UAE was independently associated with systolic (β=0.227, P=0.03), but not with diastolic (β=−0.049, P=0.59) BP, and with PP (β=0.216, P=0.01), but not with mean BP (β=0.032, P=0.72). Comparisons of these two models and stepwise regression analyses both indicated that, of the four longitudinal indices of BP, PP was the strongest predictor of UAE in men. Conclusion Chronic exposure to high pressure pulsatility is a strong risk factor for hypertensive nephropathy. Future studies should examine whether PP reduction provides additional renoprotection beyond that conferred by conventional BP goals alone.