Acute kidney injury (AKI) is commonly observed among hospital in-patients. In tandem wtih the ageing population seen in most developed countries around the world, clinicians are encountering elderly patients with AKI with increasing frequency. However, despite this clear epidemiological shift, the prevalence, outcomes and treatment considerations specific to AKI in the geriatric population are not well-defined, and very elderly patients above the age of 80 are particularly poorly represented in clinical trials in nephrology, including those relating to AKI. Hong Kong is a developed city with a rapidly ageing population and one of the longest life expectancies in the world. It also has a large number of elderly institutionalized in residential care facilities. Retrospective data from a major tertiary / quarternary centre in Hong Kong suggests that AKI is a common syndrome among the elderly, and that age is a strong predictor of a variety of adverse outcomes including both short and long-term mortality. Shockingly, a diagnosis of AKI may be a more ominous harbinger of one-year mortality than cancer or heart failure per se. Reflecting on the sobering data available from the Hong Kong experience as well as in centres around the world, this presentation will further highlight the unique considerations in managing geriatric patients with AKI, including psychosocial, functional and economic aspects. More robust and specific prognostic markers and clinical prediction criteria will need to be developed to help clinicians individualize treatment for elderly patients with AKI, particularly those who manifest geriatric syndromes such as frailty. The management of AKI in the elderly is an important challenge that will need to be confronted by health care systems around the world in the years and decades to come.