A review is presented of 164 nephrotic patients who were older than 60 years at the onset of their nephrotic syndrome, together with a review of more than 1,000 patients from the literature. The nephrotic syndrome in elderly patients is as common as in younger adults, but is often misdiagnosed as "heart failure" by primary physicians because of its rarity, especially if the jugular venous blood pressure (BP) is increased. Clinical features differ little from those of younger patients, although both an increased jugular venous BP and a presentation in potentially reversible acute renal insufficiency is more common than in the young. Inevitably, both survival and the toll of treatment side effects are higher than in their younger counterparts. Nevertheless, the effects of the nephrotic syndrome itself can be disastrous in debilitated elderly individuals and treatment, where available, should not be withheld on grounds of age alone. Membranous nephropathy is particularly common as a cause of the nephrotic syndrome in the elderly (35%), as well as minimal change disease (16%) and primary amyloidosis (12%), so that renal biopsy is even more necessary in elderly nephrotics, and again should never be withheld on grounds of age alone. It remains controversial whether neoplasias are more common in elderly nephrotics than the control population, and screening need only consist of a chest radiographic and fecal occult blood testing.