The use of renal replacement therapy (RRT) for severe acute kidney injury (AKI) is frequently necessary in the face of life-threatening complications; however, there is wide practice variation with respect to triggers for RRT initiation. Recent evidence suggests that RRT may be independently associated with impaired recovery following AKI. There are plausible mechanistic reasons why RRT may be harmful and this concept is supported by ancillary evidence in the form of studies that have assessed the impact of different modalities of RRT for AKI as well as some of the literature pertaining to initiation of chronic hemodialysis in end-stage kidney disease patients (ESKD). As such, avoiding unnecessary RRT (URRT) is a desirable goal. There is emerging evidence of strategies that may be effective to help limit URRT. These strategies primarily involve early identification of AKI and limiting iatrogenic harm once AKI is established. Further research into defining and preventing URRT may help improve the consistently poor outcomes following severe AKI with respect to development of chronic kidney disease and ESKD.