Acute neurological injury may occur in patients with end-stage kidney disease on dialysis. Less frequently, acute kidney injury requiring renal dialytic support develops following acute neurological injury. Surrounding any site of neurological injury there is a penumbra of damage which is potentially reversible. To maximize full potential neurological recovery in patients requiring renal dialytic support, it is important that treatments do not themselves cause further cerebral ischemia. Standard intermittent hemodialysis is associated with cerebral swelling even in healthy outpatients and often with episodes of intradialytic hypotension. Continuous modes of renal replacement therapy have been shown to cause fewer surges in intracranial pressure and greater stability of cerebral perfusion pressure than standard intermittent techniques. In patients with acute neurological injury, renal replacement therapy should be carefully adapted to minimize cardiovascular instability and reduce the rate of change of serum osmolality.