A narrative review of very old (≥80), frail adults with chronic kidney disease (CKD) argues that standard KDIGO-style BP targets are often misaligned with this population’s competing risks (falls, hypotension, limited life expectancy) and limited trial evidence, and instead proposes individualized BP ranges guided by frailty, prognosis, and goals of care.

Why It Matters To Your Practice

• Most CKD guideline targets were built on trials with few very old adults and virtually no frail octogenarians/nonagenarians—so “treat-to-target” can overestimate benefit and underestimate harm.

• In frail patients, outcomes that matter most often shift from long-term CKD progression to near-term function: avoiding dizziness, falls, syncope, cognitive decline, and polypharmacy burden.

• Competing risks are central: many patients are more likely to die with CKD than progress to ESKD, changing the value of aggressive BP lowering.

Clinical Benefits

• Individualizing BP goals can better match therapy intensity to realistic time-to-benefit, especially when life expectancy is limited.

• Simplifying regimens may improve adherence and reduce medication-related symptoms that erode mobility and independence.

• Aligning BP management with patient priorities (e.g., staying upright, avoiding hospitalizations) can improve shared decision-making and satisfaction with care.

Managing Risks

• Screen for frailty and geriatric syndromes (falls, orthostasis, delirium risk) before intensifying antihypertensives; these often predict harm more than kidney metrics predict benefit.

• Watch for hypotension and orthostatic symptoms after dose changes; consider home BP reads and standing BP checks in clinic.

• Use systematic deprescribing when symptoms, low diastolic pressures, or recurrent falls emerge—prioritizing the fewest meds needed to meet the patient’s goals.

The Bottom Line

• For frail adults ≥80 with CKD, BP treatment should be goal- and function-focused rather than reflexively target-driven.

• Consider individualized BP ranges, frequent reassessment, and deprescribing as core tools to balance benefit vs harm.

• Document goals of care and revisit them as frailty and prognosis evolve.