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The importance of delivering 'adequate' dialysis to patients with end-stage renal failure is widely recognized [1-4]. Despite this, little attention has been paid to the concept of 'adequacy of dialysis' in acute renal failure patients, particularly where it is likely to matter most: the intensive care unit. There are several explanations for this. Firstly, conventional forms of renal replacement with bioincompatible membranes are associated with so many technical and pathophysiological problems [5-9] that providing a treatment which controlled hyperkalaemia, limited oedema and acidosis, and lowered the blood urea concentration to 'acceptable' levels (similar to that of end-stage renal failure patients) was considered an achievement. The heterogeneity of the patient population makes it difficult to evaluate the impact of different approaches to dialytic therapy. The variability in illness severity, the many confounding factors inherent to ICU therapy, and the small numbers obtained in single institutions, further aggravate the problem. While the problems described above remain, there has been progress. There now are several safe, effective, and flexible forms of renal replacement therapy [10-12]. Illness severity scores have been developed and validated [13,14]. More accurate comparisons of populations of critically ill patients from the same or different ICUs are now possible. Ventilator techniques, haemodynamic manipulations, and approaches to the management of sepsis are increasingly performed according to consensus principles [15-18]. Finally, the ability to organize multicentre studies is increasing because of recent advances in telecommunications. Despite such advances, any discussion of the concept of adequacy of dialysis in the critically ill with acute renal failure continues to have to rely on indirect information and on physiological principles. Such physiological principles are important in denning a priori the necessary properties of an adequate renal replacement therapy.

Acute renal failure in the intensive care unit: adequacy of dialysis and the case for continuous therapies