Background: This study analyzed the relationship between the acute kidney injury (AKI) and prognosis in adult respiratory failure patients with veno-venous (V-V) extracorporeal membrane oxygenation (ECMO). Methods: We performed a retrospective study to evaluate the AKI, renal replacement therapy (RRT) and 28-day mortality of adult respiratory failure patients receiving V-V ECMO in a single center intensive care unit between Jan.1,2009 and Dec.31,2011. Results: 74 patients with respiratory failure were receiving V-V ECMO during this period. Common conditions that require V-V ECMO support were pneumonia (62.2%) and ARDS (18.9%). Overall, 60 (81.1%) patients had AKI and 46 (62.2%) patients receiving RRT during ECMO. 28 (37.8%) patients with AKI required RRT before ECMO support. Except for the patients with RRT before ECMO, 35 (76.1%) patients had no AKI and 11 (23.9%) patients had AKI (stage 1, 10.9%; stage 2, 4.3%; stage 3, 8.7%) at ECMO day. The newly developed or progressed AKI during ECMO support was 69.6% (32/46) patients. 56.3% (18/32) of AKI patients required RRT after the initiation of ECMO support. Overall, 28-day mortality rate was 59.5%. The AKIN stage was not associated with 28-day mortality. However, receiving RRT was significantly associated with increased 28-day mortality (OR, 3.92; p＜0.01). Conclusions: The incidence of AKI was high and many patients required RRT during V-V ECMO support. RRT was significantly associated with increased 28-day mortality in adult respiratory failure patients with V-V ECMO.