Background <p>Pregnancy rates in women on hemodialysis are low but increasing due to improvements in nephrological and obstetrical care. All pregnancies in dialysis patients qualify as high-risk pregnancies, but courses and outcomes of pregnancy vary depending on the underlying cause of renal failure. While more information about best practice in treatment of pregnant dialysis patients has accumulated recently, there are few cases described with systemic lupus erythematosus (SLE) as underlying disease and there is almost no information about twin pregnancies in this cohort.</p> Case presentation <p>We report the case of a successful twin pregnancy in a 30-year old hemodialysis patient with SLE who had repeatedly miscarried before. Thanks to her remaining own diuresis the required augmentation of dialysis dose was moderate with 25–27.5&#xa0;h/week, leading to largely physiological blood urea levels. In the course of pregnancy, the patient experienced severe preeclampsia, so anticipated C-section delivered both twins at 34 + 1 weeks of gestation. Both newborns were appropriate for gestational age. The boy was clinically stable but the girl initially needed intensive care. In the postpartum period the mother developed hypertensive encephalopathy and status epilepticus treated successfully. Both mother and children are well and do not suffer from any lasting damage acquired during pregnancy.</p> Conclusions <p>Pregnancy in dialysis patients is feasible even in challenging conditions as the combination of end-stage renal disease, SLE and twin pregnancy. Our case demonstrates a possible treatment regimen in a special clinical situation. By changes in medication and augmented dialysis dose appropriate to the specific individual extent of uremia, we achieved a near normal duration of pregnancy. More data on rare conditions such as twin pregnancies on dialysis with underlying autoimmune disorders are necessary to give firm advice.</p>