Haste makes waste-Should current guideline recommendations for initiation of renal replacement therapy for acute kidney injury be changed?

Abstract There is broad consensus among guideline organizations that renal replacement therapy ( RRT ) should not be delayed in case of life‐threatening conditions. However, in case of severe acute kidney injury ( AKI ) without these conditions, it is unclear whether immediate RRT has an advantage over delayed RRT . Two recently published randomized controlled trials ( AKIKI and ELAIN ) with seemingly opposite results have reignited the discussion whether guideline recommendations on initiation strategies in severe AKI should be adapted. This editorial discusses RRT initiation strategies in severe AKI , based on recent literature and highlights the potential advantages and disadvantages of immediate vs delayed start. Overall, evidence in favor of immediate compared to delayed strategies is sparse and there is wide heterogeneity across studies making it difficult to draw firm conclusions. RRT should not be delayed in case of refractory hyperkalemia, severe metabolic acidosis or pulmonary edema resistant to diuretics. In all other cases, a delayed strategy seems justified and might enhance renal recovery. RRT is not a “it doesn't hurt to try” technique and can expose the patient to a higher risk of bleeding, hemodynamic problems, under‐dosing of antibiotics, loss of nutrients, catheter‐related complications and the uncertain effects of blood‐membrane interactions. There is no compelling reason to change current guideline recommendations and research focus should shift toward the development of algorithms as a decision aid tool for RRT initiation in severe AKI .