This study evaluated the effect of pharmacist-led review on medication appropriateness in 204 older patients with chronic kidney disease (CKD) admitted to an Australian hospital. Medication appropriateness was evaluated using the Medication Appropriateness Index (MAI) prior to medication review, after review (assuming all recommendations were accepted by physicians) and after outcome (acceptance/non-acceptance) of recommendations. Overall, 95 patients (46%) received a medication review by pharmacists. The median (interquartile range) MAI score decreased significantly from a baseline of 7 (3–12) to 5 (2–10) after medication review (p < 0.001) and to 6 (2–10) after the outcome of recommendations (p < 0.01). The MAI score also decreased in patients with no medication review by a pharmacist from 6 (3–11) at admission to 5 (2–9) at discharge (p < 0.001). MAI scores declined markedly in people with all pharmacist-conducted medication review recommendations accepted (from 7 to 3; p < 0.05). Reassuringly, hospitalisation alone improved medication appropriateness. However, pharmacist-led medication review can further optimise medication appropriateness in older CKD patients, particularly when the recommendations are implemented.