The 1990 Iran earthquake affected two provinces with a population of 2.3 million, resulting in at least 13,888 deaths and 43,390 injured, and in 33,615 hospitalizations. Overall mortality among hospitalized patients was 0.17%. Acute renal failure (ARF) requiring dialysis support was diagnosed in 156 patients nationwide, with a mortality rate of 14%. Three teaching hospitals of the Tehran University of Medical Sciences admitted 495 patients, with overall mortality of 7.5%. Of these, 30 (6%) required dialysis support, with mortality of 40%, accounting for one-third of all deaths. On admission, patients with ARF were more severely injured, with significantly higher incidence of multiple trauma, peripheral nerve damage, elevated plasma concentrations of muscle enzymes, potassium and phosphate, and abnormal urinalysis. In one of the three hospitals, patients were treated with a standardized hydration protocol coupled with a cautious approach to fasciotomy. The incidence of ARF, mortality associated with ARF, and fasciotomy were lower in this group. Our limited experience suggests that this standardized approach to prevention and treatment of ARF in earthquake victims may be helpful.