Very little is known about the behavior of the hemostatic system in patients with acute kidney injury (AKI) associated with acute liver failure (ALF). Agarwal and colleagues show that patients who suffer from both ALF and AKI exhibit a higher degree of hemostasis impairment than those with normal renal function. Both anticoagulant and procoagulant factors were impaired. The development of AKI appears to displace the hemostatic equilibrium toward a more prothrombotic pattern.