Dear User, scleroderma is a small vessel disease. Capillaries who were patent previously, become narrow, leading to distal ischemia. In this condition, in order to obtain the right perfusion, heart faces increased resistances, clinically evident as hypertension. At the same time, an ischemic but vital kidney still produces tons of renin that cause hypertension. Anyway, what make me nervous is still a very high pressure in a patient on dialysis. I would suggest to search hints of an ongoing TMA, such LDH, aptoglobin, bilirubin, schistocytes. Moreover, I would like to be sure that dialytic dose is sufficient (e.g. is the dry weight correct or should we go further down in order to reduce volume dependent hypertension?). What about ongoing medications? Take care,