The aim of the present retrospective observational study was to evaluate in SSc patients the change of renal resistive index (RRI) over the time (ΔRRI) and under treatment as well as to correlate these changes with disease complications.230 patients [29 male, median age 57 (48-67) years] were enrolled. At baseline and follow-up [3.43 (2.81-4.45) years] we collected following data: disease variables, nailfold videocapilloscopy (NVC) pattern, FVC (Forced vital capacity), carbon oxide diffusing capacity (DLCO), systolic pulmonary arterial pressure (sPAP), presence of interstitial lung disease, RRI, evaluation of glomerular filtration rate (eGFR), new onset of pulmonary arterial hypertension (PAH).RRI value is high in SSc patients with digital ulcers and ACA antibodies, active and late NVC patterns, lcSSc. A significant correlation was observed between ΔRRI and ΔsPAP (r=0.17, p=0.02), with statistically higher ΔRRI (0.08 ± 0.02 versus 0.03 ± 0.05, p=0.04) in patients complicated by PAH onset. No other new onset complication was associated with ΔRRI. The ROC curve analysis confirmed the predictive role of ΔRRI in development of new PAH (AUC 0.84; 95% CI 0.75-0.93, p=0.02). In SSc patients never exposed to sildenafil, ΔRRI was higher (0.04 ± 0.05) compared to both patients exposed to sildenafil during the study period (0.01±0.05, p=0.03) or in those exposed at the time of baseline evaluation (0.00 ± 0.05, p=0.01).RRI and its variation in time are a reliable marker of SSc related vasculopathy, both in renal and extra-renal compartments.