Acute kidney injury (AKI) is, generally, a common problem in the elderly with multiple organ failure (MOFE) and what’s more, it significantly contributes to the poor outcome in these patients. Therefore, it is of great importance to protect kidney in the diagnosis and treatment of MOFE. In recent years, significant progress has been made on the role of AKI in the etiology and pathophysiology of MOFE, “normotensive ischemic acute renal failure” and “transrenal perfusion pressure” for example. These increasing new concepts are of meaningful value in the understanding of AKI in the elderly. Some new biomarkers make it possible to the early diagnosis of AKI in the MOFE in clinical practice. Multiple strategies may greatly improve the outcomes in the MOFE patients with AKI, including timely consultation with nephrologist and various managements to protect renal functions during the treatment of MOFE, such as drug dose and intervals based on renal function, suitable vasoactive drug to increase blood pressure, and rational adjustment of mechanical ventilation parameters.