Key result
High ASA-PS score linked to ~53% higher postoperative AKI risk, largely mediated by hypotension and hypoalbuminemia.
Why the study?
Preoperative comorbidities are associated with postoperative AKI, but it is unclear whether this association is direct or mediated by intraoperative hypotension and other factors.
Does intraoperative hypotension mediate the relationship between high preoperative comorbidity (ASA-PS ≥ 3) and postoperative acute kidney injury in patients undergoing non-cardiac surgery?
Cohort (n=79,788)
No
Does intraoperative hypotension mediate the relationship between high preoperative comorbidity (ASA-PS ≥ 3) and postoperative acute kidney injury in patients undergoing non-cardiac surgery?
High preoperative comorbidity (ASA-PS ≥ 3) increases the risk of postoperative acute kidney injury after non-cardiac surgery, a relationship that is partially mediated by intraoperative hypotension and hypoalbuminemia.
Answers are grounded in this paper and cite their sources.
High ASA-PS was associated with increased postoperative AKI after non-cardiac surgery; hypothesis-generating for mediation by intraoperative hypotension and hypoalbuminemia.
BACKGROUND: Preoperative comorbidities are associated with postoperative acute kidney injury (AKI). However, whether this association is direct or mediated by intraoperative hypotension (IOH) is unclear. We hypothesized that IOH mediates the relationship between preoperative comorbidities and postoperative AKI. METHODS: Data from adult patients undergoing non-cardiac surgery under general anesthesia were analyzed. Inverse probability of treatment weighting (IPTW) was applied to achieve a balance between the exposure groups by reducing the baseline differences in the measured covariates. Structural equation modeling (SEM)-based mediation analysis was conducted using the American Society of Anesthesiologists physical status (ASA-PS) classification ≥ 3 as an input and postoperative AKI as an outcome. IOH (duration of mean arterial pressure < 60 mmHg), along with albumin and hemoglobin levels, was considered a mediator. We also performed interaction analysis between patient sex and age. RESULTS: After IPTW, 8643.9 (10.8%) patients had an ASA-PS of ≥ 3. AKI occurred more frequently (4.5% vs. 6.9%, P < 0.001) in patients with ASA-PS ≥ 3. ASA-PS ≥ 3 was associated with a total effect estimate of 0.02 on the log-odds of postoperative AKI (P < 0.001). Of the total effect of ASA-PS ≥ 3 on postoperative AKI, 48% was significantly mediated by IOH (26%) and hypoalbuminemia (26%), though anemia showed no significance. The effect of high ASA-PS scores on postoperative AKI was significantly modified by sex, but not by age. CONCLUSIONS: High ASA-PS scores increase AKI risk after non-cardiac surgery, a relationship partially mediated by statistically significant pathways involving IOH and hypoalbuminemia.
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Jo et al. (2026) conducted a cohort in Postoperative acute kidney injury (AKI) (n=79,788). ASA-PS classification ≥ 3 vs. ASA-PS classification < 3 was evaluated on Postoperative acute kidney injury (AKI) (total effect estimate of 0.02 on the log-odds, 95% CI 0.02-0.03, p=<0.001). High ASA-PS scores (≥ 3) significantly increased the risk of postoperative AKI compared to lower scores (6.9% vs 4.5%, P < 0.001), with 48% of the effect mediated by intraoperative hypotension and hypoalbuminemia.
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