What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?  

I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...

One needs to make sure the patient does not have bilateral stenosis. In that circumstance, it would further worsen renal function by the change in the thermodynamics by dropping the perfusion pressure. In general, low dose ACE may be beneficial.