Can early renal replacement therapy (RRT) improve outcomes in ICU patients with acute kidney injury (AKI)? The STARRT-AKI trial, a multicenter RCT across 15 countries, assessed whether early RRT initiation improves survival compared to a delayed approach in critically ill patients with severe AKI. Over 3000 patients were randomized to either an accelerated strategy (RRT within 12 hours of eligibility) or a standard strategy (RRT only for severe complications or persistent AKI beyond 72 hours). The trial found no difference in 90-day mortality between the groups. However, 38% of patients in the standard strategy group never required RRT, suggesting unnecessary dialysis was avoided. The delayed approach also led to fewer RRT days and lower dialysis dependence at 90 days.