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Objectives Systemic lupus erythematosus (SLE) activity is believed to remit in patients with end-stage kidney disease (ESKD) requiring dialysis or transplant, although the mechanism remains elusive. This study provides a current analysis of SLE management in patients on dialysis or after transplantation by determining proportion of flares, describing clinical phenotypes, and comparing the treatment and clinical outcomes of this cohort of SLE patients who flare versus those who do not flare.Methods A single-center retrospective chart review was performed including patients 18 years and older diagnosed with SLE based on ACR classification criteria who have ESKD requiring dialysis or had undergone transplantation, with records searched between 2015 and 2022. SLE flare was defined as increased disease activity requiring a change in management and flare confirmation by a rheumatologist or nephrologist, or an increase in SLEDAI by 3 or more. Patient demographics, clinical phenotypes, and medical characteristics were recorded and analyzed between flare and no-flare groups. Categorical variables were compared between groups using either a Chi-square test or a Fisher’s Exact test, and continuous variables were compared using an ANOVA F-test.Results A total of 144 patients with SLE were included with a mean age of 48.5 years, 86.8% female, 60.4% African American, and 56.9% received transplantation ( table 1). Lupus flare occurred in 20.8% of the study population. Of the patients who experienced a flare, 43.3% occurred within one year of dialysis initiation. Patients in the flare group had higher rates of Class III/IV, Class V, and combination of lupus nephritis classes (p = 0.024). The most common flare manifestations included hematologic (66.7%), hypocomplementemia (56.7%), and kidney involvement (46.7%).Abstract PO:09:233 Table 1Conclusions SLE flares can occur in 20% of patients with ESKD despite dialysis or transplantation; flares commonly occur in the first year of renal replacement therapy with the highest risk in patients with history of class III/IV ± V LN. Current clinical practice of universal tapering of SLE medications in this population may not be appropriate given the risk of flares, and a risk-stratified approach is needed for optimal management.