Recent evidence has shown that pre-emptive or earlier renal-replacement therapy (RRT) in patients with severe acute kidney injury (AKI) and no urgent indications does not confer clinical benefit. By default, this would imply that a more judicious “watch and wait” strategy is acceptable.

The findings of AKIKI-2 reinforce that there are limitations and harm to protracted delays in RRT initiation in patients with severe and persistent AKI.

Clinicians are bound to remain challenged by a lack of clarity on the optional circumstances to initiate RRT until additional evidence emerges.

In the meantime, such uncertainty should not negate the importance of sound patient-centred practice grounded in the available evidence.

Clinicians should integrate an individual patient’s evolving critically illness, their dynamic response to interventions, the trajectory of AKI and likelihood for recovery, and importantly, patient and family preferences for care.

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