The optimal timing of renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) has been much debated. Over the past five years several studies have provided new guidance for evidence-based decision-making.

High-quality evidence now supports an approach of expectant management in critically ill patients with AKI, where RRT may be deferred up to 72 h unless a life-threatening indication develops. Nevertheless, physicians’ judgment still plays a central role in identifying appropriate patients for expectant management.

These studies give us confidence that when RRT is not yet urgently indicated and uncertainty remains whether AKI recovery might occur without RRT, expectant management may be practiced for a period of up to 72 h, while simultaneously ensuring conditions are optimised to provide the best chance of renal recovery.

Despite the additional clarity provided by these studies, sound clinical judgement is still required to tailor RRT decisions for individual patients. As with so many other aspects of critical care, one size does not fit all.

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