Background <p>The number of older patients with chronic kidney disease (CKD) is increasing worldwide. Managing clinical conditions in this population is challenging due to multimorbidity, including frailty, malnutrition, sarcopenia, and functional status impairment. This clinical scenario, in association with the decrease in kidney function, requires specific care.</p> Methods <p>We propose a new care model for older patients with moderate/advanced CKD involving a multidisciplinary and interdisciplinary team. This team includes nephrologists, geriatric physicians, nurses, and dietitians. To achieve the best results, patients’ clinical, laboratory and geriatric conditions are routinely assessed to support better shared decision-making.</p> Results <p>Since this model was created (July 2017), 607 patients &gt; 60&#xa0;years old, most of whom had CKD stages 3b to 5, have been seen at least once. Of these, 439 (72.3%) patients have been followed for a median of 19.6 (9.3, 37.1) months, with an average follow-up interval of 4.4&#xa0;months. At their first visit, most patients were overweight, 68.7% were independent with regard to activities of daily living, and 21.4% had severely impaired functional capacity. Cognitive impairment was found in 40.5% of patients. In 70.1% of the patients, the median decrease in estimated glomerular filtration rate (eGFR) was 1.4&#xa0;ml/year over time. The change in eGFR did not correlate with age (<i>r</i> = 0.011, <i>p</i> = 0.839). Among patients with CKD stage 4 or 5, 15% decided to not start dialysis based on a shared-decision making process.</p> Conclusion <p>The proposed multidisciplinary care model for older patients with CKD guides the multiprofessional identification of various conditions that might otherwise go unnoticed, while emphasizing the importance of each healthcare professional. This approach might increase the likelihood of adopting a more holistic view of patients, ultimately leading to better shared decision-making.</p> Graphical abstract <p></p>