<p>Acute kidney injury (AKI) is a common and serious perioperative complication with several diverse etiologies. Elderly surgical patients are particularly vulnerable, experiencing higher rates of AKI and suffering worse outcomes, including multiorgan dysfunction, elevated mortality rates, and a heightened risk of developing chronic kidney disease (CKD) or end-stage renal disease (ESRD). AKI also imposes a significant economic burden, increasing healthcare costs due to prolonged hospitalizations and increased resource utilization. Given the limited treatment options for AKI, prevention is paramount. This involves identifying and optimizing modifiable patient, surgical, and anesthetic risk factors, implementing evidence-based care bundles in high-risk patients, avoiding potential causes of kidney insult, and employing novel preventive strategies such as remote-ischemic preconditioning. Early diagnosis is crucial when prevention fails, allowing timely intervention before irreversible kidney damage occurs. Novel diagnostic tools show promise in improving the accuracy and timeliness of AKI detection, facilitating prompt management. While renal-replacement therapy (RRT) remains the only definitive treatment for AKI, more refined criteria for its initiation are needed to enhance its delivery and improve patient outcomes.</p>