Elderly patients, especially those with chronic kidney disease (CKD), are at high risk for the development of acute kidney injury (AKI). AKI can lead to longer hospital stays, higher mortality rates and an increased risk for the development of end-stage renal disease. Clinical variables such as combordid states, impaired renal function, polypharmacy and an increase in high-risk procedures account for some of the increased risk for AKI in elderly patients. However, specific structural, functional, hemodynamic and cellular changes that occur with aging predispose the kidney to injury in stressful states. Understanding the interactions of these intra-renal changes with aging offers the opportunity to design specific strategies that can lower the risk for the development of AKI and its complications.