Comprehensive geriatric assessment and optimisation in advanced chronic kidney disease: a systematic review and narrative synthesis examining clinical outcomes and decision-making

BACKGROUND: Older adults with advanced chronic kidney disease (CKD) frequently experience frailty, multimorbidity, cognitive impairment and functional decline, yet these geriatric syndromes are not routinely evaluated in nephrology services. Comprehensive Geriatric Assessment (CGA) can support personalised treatment decisions and optimise outcomes, but its role in CKD stages 4-5 remains unclear. This systematic review examined the impact of CGA on clinical outcomes, decision-making, and implementation within nephrology services. METHODS: A systematic review was conducted in accordance with PRISMA 2020 guidelines. MEDLINE and Embase were searched from inception to November 2025, alongside clinical trials registries. Studies were eligible if they included adults aged ≥ 60 years with CKD stages 4-5 (predialysis, dialysis-dependent, and/or undergoing kidney transplant evaluation) and evaluated CGA or a nephrology-tailored multidomain geriatric assessment incorporating ≥ 3 geriatric domains. Outcomes of interest included clinical outcomes, shared decision-making, and/or implementation features. Risk of bias was assessed using ROBINS-I and CASP tools. Narrative synthesis was undertaken due to study heterogeneity. RESULTS: Of 6,978 records identified, 5,923 were screened after duplicate removal; 39 full texts were assessed and six studies met inclusion criteria. CGA consistently identified high burdens of frailty, cognitive impairment, and functional limitation. CGA domains were strongly associated with mortality, hospitalisation, dialysis initiation, and transplant listing outcomes. Across conservative care, dialysis, and transplant pathways, CGA informed shared decision-making, treatment planning, and advance care planning. Implementation was feasible but heterogeneous, with variation in CGA models, fidelity, and workforce requirements. CONCLUSION: CGA meaningfully informs prognostic assessment and shared decision-making in older adults with advanced CKD, particularly in conservative kidney management (CKM) and transplant pathways. However, evidence for improving clinical outcomes remains limited, underscoring the need for rigorous trials and implementation frameworks to establish CGA as a core component of kidney care.