When KDIGO meets frailty: rethinking chronic kidney disease targets in adults aged 80 years and older

Abstract

Chronic kidney disease (CKD) is highly prevalent in very old adults and frequently coexists with frailty, multimorbidity, and limited life expectancy. In this population, the risk-benefit balance of standard KDIGO-style treatment targets for blood pressure, glycemic control, albuminuria, lipid management, anemia, and CKD-mineral and bone disorder is fundamentally altered. The clinical trials underpinning these recommendations enrolled few very old patients and virtually no frail octogenarians or nonagenarians, so the evidence base is poorly aligned with the realities of advanced age. Summary: This narrative review examines CKD progression in frail very old adults, with particular attention to frailty, geriatric syndromes, and competing risks of end-stage kidney disease and death. It then proposes a pragmatic framework to adapt KDIGO-style targets by incorporating frailty assessment, life expectancy, and patient goals of care into therapeutic decisions. For each major treatment domain, the discussion moves from abstract targets to clinically meaningful, individualized ranges, emphasizing treatment simplification, systematic deprescribing, and preservation of physical and cognitive function as primary outcomes. Key Messages: The review identifies urgent research priorities, including trials that intentionally enroll frail older adults, evaluations of deprescribing strategies, and studies comparing conservative kidney management with dialysis in this highly vulnerable and rapidly growing patient group.