Kidney involvement is common in systemic lupus erythematosus (SLE) and is seen in 40-70% of patients. Of these patients, 20-30% progress to end-stage renal failure (ESRD) requiring renal replacement therapy (RRT) within 10 years of lupus diagnosis. Previous studies have reported a decrease in clinical and serum activity in SLE once dialysis is initiated, a phenomenon known as ‘burnout’. The mechanism is unknown and may be related to uremia and/or dialysis-induced immune dysfunction, while on the other hand there are hypotheses that the phenomenon of ‘burnout’ may represent the natural course of the disease. Interestingly, recent evidence suggests that SLE ‘relapse’ is actually common in ESRD, especially in the 1st year of RRT. Case series have reported >50% of ESRD patients with SLE have flares. However, current information on lupus flares after dialysis is scarce and controversial, so a study by Prof. Ana Barrera-Vargas et al. from the Department of Rheumatology and Immunology in Mexico City aimed to identify the risk factors for SLE flares in ESRD patients entering RRT, and the article was published in a recent issue of Rheumatology. The researchers conducted a retrospective case-control study at a tertiary care hospital in Mexico City from 1993-2014. The included cases were patients with systemic lupus erythematosus (SLE) who had extrarenal lupus flares after entering RRT. Controls were SLE patients who entered ESRD but did not have extra-renal lupus flares. Demographic characteristics, clinical indicators, and immunologic markers were recorded for both groups. A total of 88 patients were included in the study, including 38 case patients (who had 50 extrarenal flares) and 50 control patients. There was a higher proportion of males in the case patients than in the control patients (24% versus 8%). The most common extrarenal relapse presentation was hematologic (42%), followed by cutaneous mucosal (38%), joint (30%), plasmapheresis (16%), myocardial pericarditis (12%), fever (12%), diffuse alveolar hemorrhage (6%), and cutaneous vasculitis (2%). Independent risk factors for relapse included age at the time of initiation of RRT, past history of hematologic activity, positive anticardiolipin antibody IgM, and low C4 levels. Based on these findings, the investigators concluded that SLE patients remain at risk for extrarenal activity after entering RRT. The most common manifestation of extrarenal relapse was hematologic manifestation, which was associated with a previous history of active hematologic disease and anticardiolipin antibody positivity as independent risk factors. Lower C4 levels and younger age at the start of RRT are likewise associated with the risk of extrarenal activity in patients with SLE. Patients with these characteristics should be followed more closely in order to detect and treat SLE relapses in a timely manner.