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An elevated preoperative C-reactive protein-to-albumin ratio (CAR) is independently associated with increased risks of in-hospital mortality, 30-day mortality, ICU admission, and prolonged hospital stays in surgical patients with chronic kidney disease. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

March 3, 2026Open Access

Association of the C-reactive protein–to–albumin ratio (CAR) with clinical outcomes in chronic kidney disease patients undergoing surgery: a retrospective cohort analysis of the INSPIRE database

Key Points

An elevated c-reactive protein–albumin ratio is linked to increased in-hospital mortality in CKD patients undergoing surgery, indicating severe risk levels.
In-hospital mortality risks are increased by 1.08 times for each unit increase in log2-CAR among 2338 patients, emphasizing the importance of monitoring this ratio.

Structured PICO

Does an elevated preoperative C-reactive protein-to-albumin ratio (CAR) predict worse clinical outcomes in chronic kidney disease patients undergoing surgery?

Population

2,338 adult chronic kidney disease (CKD) patients undergoing surgery, average age 60.7 ± 14.8 years, 65.8% male, from a single-center registry (Seoul National University Hospital).

Intervention

Elevated preoperative C-reactive protein-to-albumin ratio (CAR) upon admission (highest quartile / Q4)

Comparator

Lower preoperative C-reactive protein-to-albumin ratio (CAR) upon admission (lowest quartile / Q1)

Outcome

In-hospital mortalityhard clinical

An elevated preoperative C-reactive protein-to-albumin ratio is a readily available marker that independently predicts in-hospital mortality, 30-day mortality, and ICU admission in CKD patients undergoing surgery.

Abstract

To evaluate the relationship between C‑reactive protein–albumin ratio (CAR) and clinical outcomes among perioperative patients with chronic kidney disease (CKD). This study retrospectively analyzed CKD patients who underwent surgery using data from the INSPIRE database, a single-center registry of perioperative clinical, laboratory, and outcome data from adult surgical patients at Seoul National University Hospital. Patients were stratified into quartiles on the basis of their CAR upon admission. Associations between CAR and outcomes were evaluated using adjusted Cox proportional hazards models (in‑hospital and 30‑day mortality), multivariable logistic regression (ICU admission), and a generalized linear model (length of hospitalization). The cohort comprised 2338 CKD patients, with an average age of 60.7 ± 14.8 years, and 65.8% were males. After controlling for possible confounding factors, an elevated log2-CAR was independently associated with in-hospital mortality (HR = 1.08, 95% CI 1.02–1.15; p = 0.009), with the highest quartile (Q4) showing a 1.99-fold higher risk than Q1 (p < 0.001). The secondary outcomes demonstrated similar trends: a higher CAR correlated with increased 30-day mortality (adjusted HR = 1.1, 95% CI 1.02–1.18; p = 0.012), ICU admission (adjusted OR = 1.05, 95% CI 1.01–1.09; p = 0.021) and a prolonged hospital stay (adjusted exp(β) = 1.06; 95% CI 1.05–1.08; p < 0.001). Subgroup and sensitivity analyses yielded consistent findings. An elevated CAR is positively associated with increased risks of in‑hospital death, 30-day mortality, ICU admission, and longer hospital stays in CKD patients who have undergone surgery. Our findings support the use of the preoperative CAR, a readily available, cost-effective marker, to inform risk stratification and guide perioperative care in patients with CKD. Not applicable.

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