Failure of early creatinine recovery predicts poor survival after emergency surgery for bowel perforation or infarction

Hyun Il Kim; Min Hong Lee; Byung Jun Jeon; Yoon Mo Kim; Mi Kyung Oh; Min Gyu Kim

doi:10.4266/acc.003625

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Original Article Surgery Failure of early creatinine recovery predicts poor survival after emergency surgery for bowel perforation or infarction: Acute and Critical Care 2026;41(1):126-135.
DOI: https://doi.org/10.4266/acc.003625
Published online: February 27, 2026

Hyun Il Kim^1,*

, Min Hong Lee^1,*

, Byung Jun Jeon¹

, Yoon Mo Kim²

, Mi Kyung Oh²

, Min Gyu Kim¹

¹Department of Surgery, Hanyang University Guri Hospital, Hanyang University School of Medicine, Guri, Korea

²Department of Anesthesiology, Hanyang University Guri Hospital, Hanyang University School of Medicine, Guri, Korea

Corresponding author: Min Gyu Kim Department of Surgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 11923, Korea Tel: +82-31-560-2294, Fax: +82-31-566-4409, Email: md9650@hanyang.ac.kr

*These authors contributed equally to this work.

• Received: August 28, 2025 • Revised: October 26, 2025 • Accepted: November 28, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
KEY MESSAGES
NOTES
REFERENCES

Abstract

Background
Early postoperative recovery of kidney function is critical in emergency bowel surgery. This study evaluated the prognostic value of preoperative creatinine elevation (PCE) and early creatinine recovery (ECR).
Methods
A total of 424 patients underwent emergency surgery for bowel perforation or ischemia from January 2019 to December 2024. Sixteen trauma-related cases (including procedure-related injuries) were excluded, leaving 408 patients for analysis. Of these, 35 patients with end-stage renal disease or chronic kidney disease—either pre-existing or newly diagnosed during hospitalization—were excluded. ECR was defined as a decrease in serum creatinine to <1.3 mg/dl by postoperative day (POD) 3. PCE was defined as serum creatinine >1.3 mg/dl. Associations with postoperative complications and 30-day mortality were estimated using multivariable logistic regression and reported as adjusted odds ratios (aORs) with 95% CIs.
Results
PCE occurred in 18.5% (69/373) of the tested patients; among these, 58.0% (40/69) achieved ECR by POD 3. Failure of ECR was associated with severe complications (93.1% vs. 27.5%, P<0.001) and higher mortality (72.4% vs. 7.5%, P<0.001). In multivariable analysis, ECR failure independently predicted complications (aOR, 28.71; 95% CI, 5.44–151.57) and 30-day mortality (aOR, 32.37; 95% CI, 7.74–135.40; P<0.001 for both).
Conclusions
Failure to achieve ECR is independently associated with poor survival after emergency laparotomy for peritonitis. This finding supports the use of a creatinine-based checkpoint to trigger intensified monitoring and targeted rescue interventions.
Key Words: creatinine; intestinal perforation; mesenteric ischemia; mortality; renal insufficiency

INTRODUCTION

Acute kidney injury (AKI) is a well-recognized predictor of adverse outcomes in surgical patients, particularly in those undergoing emergency abdominal procedures [1-5]. Most previous studies have adopted the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, incorporating dynamic changes in serum creatinine (SCr) or urine output [6]. In acute surgical emergencies, preoperative assessment of urine output in accordance with KDIGO criteria is often unfeasible due to time constraints, limiting the applicability of KDIGO-based determination of preoperative AKI.

In routine clinical settings, a single preoperative measurement of SCr exceeding the normal range can provide rapid and objective indication of renal impairment, supporting timely perioperative risk assessment. Nevertheless, the prognostic relevance of an absolute preoperative SCr cutoff independent of KDIGO criteria has not been investigated adequately in patients undergoing emergency bowel surgery. Postoperative restoration of renal function is increasingly recognized as a critical determinant of surgical outcomes [1-5,7,8]. Although prior research has predominantly addressed the occurrence and severity of AKI, the influence of early postoperative creatinine recovery on prognosis in the emergency surgical setting remains insufficiently defined. Specifically, the prognostic significance of failure of early creatinine recovery (ECR), defined as a reduction in SCr to <1.3 mg/dl by postoperative day (POD) 3, has yet to be elucidated.

The objective of this study was to evaluate the prognostic impact of preoperative creatinine elevation (PCE) and ECR in patients undergoing emergency surgery for bowel perforation or ischemia. We hypothesized that failure of ECR would be strongly associated with increased postoperative morbidity and higher mortality. Rather than detecting renal injury at its onset, a postoperative creatinine-based assessment may allow early postoperative identification of patients at risk for persistent renal dysfunction and adverse outcomes.

MATERIALS AND METHODS

The study protocol was reviewed and approved by the Institutional Review Board of Hanyang University Guri Hospital (No. 2025-02-012). The requirement for informed consent was waived due to the retrospective nature of the investigation.

Patient Selection and Study Design

This was a retrospective, single-center cohort study conducted at Hanyang University Guri Hospital, including 424 consecutive patients who underwent emergency abdominal surgery for bowel perforation or ischemia between January 2019 and December 2024. Patients with bowel ischemia or infarction who were managed without bowel resection (e.g., treated successfully with adhesiolysis or other conservative surgical procedures) and those with perforation secondary to stage IV malignancy were not included in the initial cohort. Among the 424 surgically treated patients, 16 cases in which the perforation was attributable to trauma, including iatrogenic causes, were excluded, leaving 408 patients for inclusion in the final study cohort. Patients were initially stratified according to preoperative SCr level into a normal SCr group (≤1.3 mg/dl, n=304) and an elevated SCr group (>1.3 mg/dl, n=69). Patients with end-stage renal disease or chronic kidney disease (CKD), either pre-existing or newly recognized during admission, were excluded from baseline comparisons and from ECR analyses because a fixed SCr cutoff of 1.3 mg/dl is not applicable to chronic kidney dysfunction and may bias classification. Newly recognized CKD during the index admission was confirmed in consultation with nephrology, based on preadmission records and nephrology notes. When prior data were unavailable, supportive abdominopelvic computed tomography features of chronic renal parenchymal disease (e.g., bilateral renal atrophy and diffuse cortical thinning/scarring) were examined as supportive evidence for CKD.

Patients with elevated preoperative SCr were further categorized based on ECR, defined as a decrease in SCr to <1.3 mg/dl by POD 3, into an ECR group (n=40) and an ECR failure group (n=29) (Figure 1). All surgeries were performed by board-certified gastrointestinal surgeons with substantial expertise in emergency abdominal procedures.

Definitions of Clinical Variables

PCE was defined as SCr level exceeding 1.3 mg/dl on the most recent measurement prior to emergency surgery. ECR was defined as postoperative decrease in SCr to less than 1.3 mg/dl by POD 3. Failure of ECR was defined as not meeting the above criterion, including patients who died before POD 3. Shock was defined as persistent hypotension requiring vasopressor support to maintain a mean arterial pressure ≥65 mm Hg in the presence of suspected or confirmed infection. Hypoalbuminemia was defined as a serum albumin concentration <3.5 g/dl on preoperative laboratory testing.

Assessment of Renal Function

Postoperative renal function was evaluated using SCr values rather than full KDIGO criteria. Because this study involved emergency laparotomy cases, continuous urine-output data and preoperative serial creatinine measurements were frequently unavailable. To ensure consistency across all patients, renal recovery was assessed based on the change in SCr from the preoperative value to POD 3. This pragmatic approach reflects early renal recovery while accommodating the clinical constraints of emergency settings, where accurate urine monitoring is often not feasible.

Clinical Data and Parameters

Patient information was retrospectively retrieved from institutional electronic medical records. Variables collected included demographic characteristics (age, sex, and comorbidity), history of prior major abdominal surgery, American Society of Anesthesiologists (ASA) physical status classification, and interval from symptom onset to operative intervention. Laboratory data obtained before surgery comprised serum albumin and SCr measurements. ASA classification was determined by the attending anesthesiologist immediately prior to induction of anesthesia.

Surgical Outcomes

In this study, surgical outcomes of interest included duration of surgery, incidence of major postoperative complications, mortality within 30 days of the operation, and length of postoperative hospital stay. Postoperative complications were defined as major complications corresponding to Clavien-Dindo classification grade III or higher, requiring surgical, endoscopic, or radiologic intervention [9]. In addition, multi-organ dysfunction attributable to septic shock was regarded as a major complication. Postoperative mortality was defined as any death occurring within 30 days after surgery, regardless of the underlying cause.

Statistical Analysis

All statistical analyses were performed using IBM SPSS statistics version 21.0 (IBM Corp.). The normality of continuous variables was assessed using the Shapiro-Wilk test. Continuous variables are summarized as mean±standard deviation or median (interquartile range), as appropriate, and compared between groups using Student t-test for normally distributed data or the Mann-Whitney U-test for non-normally distributed data (e.g., postoperative hospital stay). Categorical variables are presented as number (%) and compared using the chi-square test or Fisher’s exact test, as appropriate. Variables with a P value <0.10 in univariable analyses, together with clinically relevant covariates, were entered into a multivariable logistic regression model to identify independent predictors of postoperative complications and 30-day mortality. Results are reported as adjusted odds ratios (aORs) with 95% CIs. Model calibration and discrimination were assessed using the Hosmer-Lemeshow test and the area under the receiver-operating-characteristic curve. Multicollinearity was assessed using variance inflation factor (VIF); no VIF exceeded 10. Two-sided P<0.05 was considered statistically significant. Missing data were handled by complete-case analysis.

Postoperative treatment variables (e.g., diuretic exposure [dose/timing], vasopressor exposure [dose/duration/peak], and continuous renal replacement therapy initiation/indication) were not included as covariates because they were not uniformly and systematically captured across all patients, raising the risk of missing-data and information bias. Moreover, these therapies typically occur after the index surgery in response to the evolving clinical course (e.g., ECR non-recovery, persistent sepsis) and thus may function as post-exposure mediators; adjusting for them could introduce over-adjustment/mediator bias and attenuate the prognostic signal of ECR. Accordingly, multivariable models were limited to preoperative and operative covariates, whereas postoperative treatments are presented, where available, as descriptive data only.

RESULTS

Preoperative Characteristics

Patients with PCE were older (73.6±13.4 vs. 63.6±16.6 years, P<0.001) and more frequently presented with symptom onset ≥48 hours (50.7% vs. 29.3%, P<0.001) and preoperative septic shock (65.2% vs. 11.8%, P<0.001) (Table 1). They also had more frequent comorbidities (91.3% vs. 64.8%, P<0.001) and a higher ASA score ≥E4 (75.4% vs. 24.0%, P<0.001). Postoperative complications (55.1% vs. 12.8%, P<0.001) and 30-day mortality (34.8% vs. 3.6%, P<0.001) were markedly higher in the PCE group, whereas hospital stay did not differ significantly.

Clinical Characteristics and Outcomes According to ECR

Among patients with PCE, those who achieved ECR demonstrated markedly better clinical outcomes compared with those with failure of ECR (Table 2). The failure group had a significantly higher incidence of preoperative shock (82.8% vs. 52.5%, P=0.009) and hypoalbuminemia (<3.5 g/dl; 75.8% vs. 52.5%, P=0.048). Postoperative complications were substantially more common in the failure group (93.1% vs. 27.5%, P<0.001), and 30-day mortality was strikingly higher (72.4% vs. 7.5%, P<0.001). Other preoperative variables, including age, sex, comorbidities, ASA classification, surgical history, and surgical approach, as well as postoperative hospital stay, did not differ significantly between the two groups.

Univariate Analysis of Risk Factors for Postoperative Complications and Mortality

In univariate analysis (Table 3), preoperative shock, ASA class E4, gastric origin of peritonitis, perforation as the underlying cause, hypoalbuminemia, and failure of ECR were significantly associated with postoperative complications. Shock, low serum albumin, and ECR failure were also associated with higher 30-day mortality. Among all variables, ECR failure showed the strongest associations, with complication and mortality rates exceeding 90% and 70%, respectively.

Multivariable Analysis of Prognostic Factors

Multivariable logistic regression identified failure of ECR as the sole independent predictor of both complications (aOR, 28.71; 95% CI, 5.44–151.57) and 30-day mortality (aOR, 32.37; 95% CI, 7.74–135.40; P<0.001 for both), as shown in Table 4. No other variables remained significant after adjustment.

DISCUSSION

In this single-center cohort of patients undergoing emergency surgery for peritonitis due to bowel perforation or infarction, failure of ECR was independently associated with higher rates of severe postoperative complications and mortality. The emergency general surgery literature has largely emphasized AKI incidence and preoperative risk factors [1,2,4]. The data suggest that not only AKI occurrence, but also speed of renal recovery, carry prognostic relevance. This finding is consistent with observations from cardiac surgery regarding AKI persistence and delayed recovery [7,10,11]. Because information about urine output is commonly incomplete and preoperative serial creatinine is constrained in urgent care, a POD 3 creatinine–based criterion offers a pragmatic and reproducible approach to postoperative risk assessment.

These observations are consistent with widely used frameworks grading the severity of peritonitis [12-14]. Within our cohort, failure of ECR was accompanied by a greater burden of shock, lower albumin levels, and inferior outcomes. Because these features map onto constructs embedded in existing scores—hemodynamic instability, organ dysfunction, and generalized contamination—ECR failure may provide incremental, real-time information about unresolved sepsis and suboptimal perfusion that preoperative risk scores alone may miss.

Source control is the key modifiable determinant in peritonitis. Guidance and observational data generally recommend achieving control within 6–12 hours; postponement is associated with increased mortality [15-17]. Continued intra-abdominal contamination drives inflammation and microvascular dysfunction, plausibly sustaining renal hypoperfusion and tubular stress. In practice, this is reflected by ECR failure by POD 3. Incorporating a POD 3 creatinine–based checkpoint offers a structured opportunity to judge source-control sufficiency. Lack of recovery should prompt aggressive evaluation for residual infection (e.g., undrained collections, anastomotic leak, ischemic segments) and optimization of hemodynamics. Sepsis-associated renal injury likely reflects an interplay of macro- and microcirculatory disturbances, endothelial-glycocalyx injury, and tubular–mitochondrial stress. Ongoing intra-abdominal contamination can sustain systemic inflammation and microvascular dysfunction, perpetuating renal hypoperfusion despite apparently adequate global hemodynamics, which in turn delays tubular recovery by the early postoperative period [18].

Among patients with bowel ischemia/necrosis, the recognized high case fatality of mesenteric ischemia, especially when definitive management is delayed, was evident in our cohort [19-22]. Pathophysiologic features such as systemic hypoperfusion, reperfusion injury, and endotoxemia may sustain kidney injury and hinder early recovery. We observed greater organ failure and mortality in patients with ischemic etiologies. POD 3 renal non-recovery exacerbated the outcomes of this high-risk subset and could serve as a practical trigger for expedited second-look surgery, re-exploration, or vascular evaluation.

The biological basis for considering the timing of renal recovery is robust. Cardiac surgery studies demonstrate that AKI persistence and delayed recovery are monotonically associated with mortality and adverse long-term outcomes even at lower severity [7,10,11]. Our findings suggest a parallel in contaminated emergency laparotomy: ECR failure by POD 3 may indicate unresolved hemodynamic/inflammatory stress and identify a pragmatic opportunity for intervention. A care bundle triggered by POD 3 non-recovery, including reassessment of fluid responsiveness, mean arterial pressure targets to avoid venous congestion, kidney-protective fluid strategies, early nephrology involvement, and imaging to confirm source-control adequacy, should be evaluated prospectively [23].

From a practical standpoint, ECR failure by POD 3 may serve as a real-time indicator of unresolved sepsis, hemodynamic instability, or inadequate source control. Recognizing this checkpoint early could prompt timely interventions aimed at preventing further deterioration. A pragmatic care bundle may include (1) reassessment of fluid balance and perfusion targets to avoid both hypoperfusion and venous congestion; (2) early nephrology consultation for renal optimization and avoidance of nephrotoxic agents; (3) targeted imaging to evaluate for residual intra-abdominal infection, anastomotic leakage, or ischemic bowel segments; and (4) consideration of second-look surgery or re-exploration when source control adequacy remains uncertain. Integrating this ECR-triggered bundle into postoperative monitoring could help clinicians identify high-risk patients who would benefit from intensified surveillance and early intervention.

Conceptually, the ECR criterion complements established severity indices such as the Mannheim Peritonitis Index (MPI), P-POSSUM (Portsmouth modification of the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity), National Emergency Laparotomy Audit (NELA) risk model [24,25]. These traditional models primarily rely on preoperative physiological and operative parameters, whereas ECR reflects the dynamic postoperative course and recovery of organ function. By capturing ongoing hemodynamic and inflammatory stress beyond the intraoperative phase, ECR may provide incremental prognostic value and help identify patients at risk even after apparently adequate source control. Future studies should evaluate whether incorporating ECR into existing scoring systems improves calibration and predictive accuracy in emergency abdominal surgery.

This study relied solely on SCr-based assessment rather than the complete KDIGO definition of AKI, as urine-output data were incomplete in many emergency cases. In real-world emergency laparotomy practice, continuous urine measurement is often impractical due to hemodynamic instability, urgent surgical timelines, and frequent inter-hospital transfers. Under these circumstances, a POD 3 SCr checkpoint provides a simple and reproducible method to evaluate renal recovery. Previous reports have demonstrated that the persistence or resolution of creatinine elevation within the first 72 hours after surgery strongly correlates with postoperative morbidity and mortality, even when urine-output data are unavailable. Therefore, although omission of the urine-output component represents a limitation, the POD 3 creatinine-based approach offers a clinically feasible and standardized surrogate for early renal recovery and prognostication in the emergency surgical setting. Nevertheless, the use of a single absolute SCr threshold (1.3 mg/dl) does not fully account for variation by sex, age, or muscle mass and may therefore risk misclassification; accordingly, we frame POD-3 SCr as a pragmatic checkpoint rather than a diagnostic definition.

This study benefits from data derived from uniform surgical practice patterns and a clear, bedside-applicable definition of ECR assessed on POD 3. Limitations include the retrospective, single-center design; reliance on SCr without standardized urine output measurements; and the potential for residual confounding, such as unmeasured gradations of peritoneal contamination or microbiology. Even so, the simplicity and clinical reach of a POD 3 ECR criterion, combined with its strong independent association with outcomes, support its use as an actionable checkpoint within emergency general surgery pathways. Future studies should assess whether integrating ECR with the MPI or P-POSSUM/NELA improves calibration and whether care bundles triggered by ECR non-recovery reduce complications and mortality.

This study has several limitations. It was a retrospective, single-center analysis with a relatively small ECR failure group (n=29), which may limit external validity and introduce selection bias related to institutional practice patterns. Exclusion of CKD cases may also have narrowed the range of renal dysfunction encountered in real-world settings. Nevertheless, uniform perioperative management by experienced gastrointestinal surgeons ensured internal consistency. The pragmatic, SCr-based POD 3 checkpoint offers a simple and reproducible tool for postoperative risk assessment when urine-output criteria are impractical. Future large-scale prospective multicenter studies are needed to validate these findings and to evaluate prediction frameworks that combine sex-specific upper limits of normal, eGFR, and relative changes in creatinine together with the POD-3 creatinine checkpoint to improve calibration and early prognostication.

In emergency laparotomy for peritonitis due to bowel perforation or infarction, failure of ECR identifies a high-risk phenotype with numerous major complications and 30-day mortality. This pragmatic checkpoint augments perioperative risk models by indicating persistent sepsis and hemodynamic stress that may be reversible. Patients without ECR by POD 3 should receive intensified monitoring and targeted, goal-directed interventions.

KEY MESSAGES

▪ Preoperative serum creatinine elevation (>1.3 mg/dl) is a significant marker of high perioperative risk in emergency surgery for bowel perforation or infarction.

▪ Failure to achieve early creatinine recovery (ECR) by postoperative day 3 is strongly associated with markedly increased postoperative mortality.

▪ Early identification of patients without ECR can facilitate intensified postoperative monitoring and timely supportive interventions to improve survival outcomes.

NOTES

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

The authors express their sincere gratitude to the surgical and nursing teams of the Department of Surgery, Hanyang University Guri Hospital, for their dedicated care of the patients included in this study.

AUTHOR CONTRIBUTIONS

Conceptualization: MHL, HIK, MGK. Data curation: MHL, HIK, BJJ. Formal analysis: MHL, HIK. Methodology: MHL, HIK, MGK. Project administration: MGK. Visualization: MHL, HIK, BJJ. Writing – original draft: MHL, HIK, YMK. Writing – review & editing: MGK, MHL, HIK, BJJ, MKO. All authors read and agreed to the published version of the manuscript.

Figure 1.

Study flowchart of patient selection. A total of 424 patients underwent emergency surgery for bowel perforation or infarction. After excluding trauma-related cases (n=16) and patients with end-stage renal disease (ESRD) or chronic kidney disease (CKD) (n=35), 373 patients were analyzed. Patients were stratified by preoperative serum creatinine (SCr) level and early creatinine recovery (ECR) status by postoperative day (POD) 3.

Table 1.

Clinical characteristics and surgical outcomes by elevated preoperative creatinine status

Variable	According to PCE		P-value
Variable	PCE (n=69)	No PCE (n=304)	P-value
Age (yr)	74±13	64±17	<0.001
Sex			0.164
Male	35 (50.7)	182 (59.9)
Female	34 (49.3)	122 (40.1)
Symptom onset timing			<0.001
≥48 hr	35 (50.7)	89 (29.3)
Occurrence of shock before surgery	45 (65.2)	36 (11.8)	<0.001
Comorbidity			<0.001
Yes	63 (91.3)	197 (64.8)
ASA score			<0.001
E3	17 (24.6)	231 (76.0)
≥E4	52 (75.4)	73 (24.0)
History of major abdominal surgery	7 (10.1)	22 (7.2)	0.415
Serum creatinine level (mg/dl)	2.3±1.4	0.8±0.2	<0.001
Albumin level (serum)			<0.001
<3.5 g/dl	43 (62.3)	97 (31.9)
Source of peritonitis			0.116
Gastric or duodenal origin	27 (39.1)	118 (38.8)
Small bowel origin	14 (20.3)	95 (31.3)
Colon or rectal origin	28 (40.6)	91 (29.9)
Etiology of peritonitis			0.326
Perforation	49 (71.0)	233 (76.6)
Ischemia or infarction	20 (29.0)	71 (23.4)
Postoperative complications	38 (55.1)	39 (12.8)	<0.001
Postoperative mortality (≤30 days after surgery)	24 (34.8)	11 (3.6)	<0.001
Hospital stay after surgery (day)	19.8±24.7	14.7±11.2	0.101

Values are presented as mean±standard deviation or number (%).

PCE: preoperative creatinine elevation; ASA: American Society of Anesthesiologists.

Table 2.

Clinical characteristics and outcomes by POD 3 ECR

Variable	According to ECR		P-value
Variable	Recovery (n=40)	No recovery (n=29)	P-value
Age (yr)	75±14	72±13	0.159
Sex			0.888
Male	20 (50.0)	15 (51.7)
Female	20 (50.0)	14 (48.3)
Symptom onset timing			0.264
≥48 hr	18 (45.0)	17 (58.6)
Occurrence of shock before surgery	21 (52.5)	24 (82.8)	0.009
Comorbidity			0.679
Yes	37 (92.5)	26 (89.7)
ASA score			0.075
E3	13 (32.5)	4 (13.8)
≥E4	27 (67.5)	25 (86.2)
History of major abdominal surgery	3 (7.5)	4 (13.8)	0.393
Serum creatinine level (mg/dl)	1.6±0.3	2.9±1.6	<0.001
Albumin level (serum)			0.048
<3.5 g/dl	21 (52.5)	22 (75.8)
Source of peritonitis			0.985
Gastric or duodenal origin	16 (40.0)	11 (37.9)
Small bowel origin	8 (20.0)	6 (20.7)
Colon or rectal origin	16 (40.0)	12 (41.4)
Etiology of peritonitis			0.196
Perforation	26 (65.0)	23 (79.3)
Ischemia or infarction	14 (35.0)	6 (20.7)
Surgical method			0.661
Laparoscopy	27 (67.5)	21 (72.4)
Open	13 (32.5)	8 (27.6)
Postoperative complications	11 (27.5)	27 (93.1)	<0.001
Postoperative mortality (≤30 days after surgery)	3 (7.5)	21 (72.4)	<0.001
Septic shock with MOF		18
Anastomosis leakage → sepsis → MOF	2	1
Respiratory failure		2
Postoperative cardiac arrest	1
Day of hospital stay after surgery (day)	12.9±14.6	20.6±10.9	0.370

Values are presented as mean±standard deviation or number (%).

POD: postoperative day; ECR: early creatinine recovery; PCE: preoperative creatinine elevation; ASA: American Society of Anesthesiologists; MOF: multiorgan failure.

Table 3.

Univariate analyses of prognostic factors for postoperative complications and mortality

Variable	Number	Complication	P-value	Mortality	P-value
Age (yr)			0.989		0.640
<75	29	16 (55.2)		11 (37.9)
≥75	40	22 (55.0)		13 (32.5)
Sex			0.187		0.930
Male	35	22 (62.9)		12 (34.3)
Female	34	16 (47.1)		12 (35.3)
Onset (hr)			0.404		0.356
<48	34	17 (50.0)		10 (29.4)
≥48	35	21 (60.0)		14 (40.0)
Shock			0.008		0.005
Yes	45	30 (66.7)		21 (46.7)
No	24	8 (33.3)		3 (12.5)
ASA score			<0.001		0.087
E3	17	6 (35.3)		3 (17.6)
E4	52	32 (61.5)		21 (40.4)
Comorbidity			0.263		0.938
Yes	63	36 (57.1)		22 (34.9)
No	6	2 (33.3)		2 (33.3)
History of previous surgery			0.359		0.190
Yes	7	5 (71.4)		4 (57.1)
No	62	33 (53.2)		20 (32.3)
Source of peritonitis			0.009		0.441
Gastric/duodenal	27	21 (77.8)		12 (44.4)
Small bowel	14	5 (35.7)		4 (28.6)
Colon/rectum	28	12 (42.9)		8 (28.6)
Etiology of peritonitis			0.032		0.276
Perforation	49	31 (63.3)		19 (38.8)
Infarction	20	7 (35.0)		5 (25.0)
Albumin (g/dl)			0.031		0.035
<3.5	43	28 (65.1)		19 (44.2)
≥3.5	26	10 (38.5)		5 (19.2)
Failure of ECR			<0.001		<0.001
Yes	29	27 (93.1)		21 (72.4)
No	40	11 (27.5)		3 (7.5)
Surgical method			0.819		0.139
Open	21	12 (57.1)		10 (47.6)
Laparoscopy	48	26 (54.2)		14 (29.2)

Values are presented as number (%).

ASA: American Society of Anesthesiologists; ECR: early creatinine recovery.

Table 4.

Multivariable logistic regression for postoperative complications and mortality

Variable	Postoperative complication		P-value	Postoperative mortality		P-value
Variable	aOR	95% CI	P-value	aOR	95% CI	P-value
Perforation (vs. infarction)	4.66	0.95–22.85	0.058
Failure of ECR (vs. ECR)	28.71	5.44–151.57	<0.001	32.37	7.74–135.40	<0.001

aOR: adjusted odds ratio; ECR: early creatinine recovery.

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Failure of early creatinine recovery predicts poor survival after emergency surgery for bowel perforation or infarction

Acute Crit Care. 2026;41(1):126-135. Published online February 27, 2026

DOI: https://doi.org/10.4266/acc.003625

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Figure

Failure of early creatinine recovery predicts poor survival after emergency surgery for bowel perforation or infarction

Figure 1. Study flowchart of patient selection. A total of 424 patients underwent emergency surgery for bowel perforation or infarction. After excluding trauma-related cases (n=16) and patients with end-stage renal disease (ESRD) or chronic kidney disease (CKD) (n=35), 373 patients were analyzed. Patients were stratified by preoperative serum creatinine (SCr) level and early creatinine recovery (ECR) status by postoperative day (POD) 3.

Figure 1.

Failure of early creatinine recovery predicts poor survival after emergency surgery for bowel perforation or infarction

Variable	According to PCE		P-value
Variable	PCE (n=69)	No PCE (n=304)	P-value
Age (yr)	74±13	64±17	<0.001
Sex			0.164
Male	35 (50.7)	182 (59.9)
Female	34 (49.3)	122 (40.1)
Symptom onset timing			<0.001
≥48 hr	35 (50.7)	89 (29.3)
Occurrence of shock before surgery	45 (65.2)	36 (11.8)	<0.001
Comorbidity			<0.001
Yes	63 (91.3)	197 (64.8)
ASA score			<0.001
E3	17 (24.6)	231 (76.0)
≥E4	52 (75.4)	73 (24.0)
History of major abdominal surgery	7 (10.1)	22 (7.2)	0.415
Serum creatinine level (mg/dl)	2.3±1.4	0.8±0.2	<0.001
Albumin level (serum)			<0.001
<3.5 g/dl	43 (62.3)	97 (31.9)
Source of peritonitis			0.116
Gastric or duodenal origin	27 (39.1)	118 (38.8)
Small bowel origin	14 (20.3)	95 (31.3)
Colon or rectal origin	28 (40.6)	91 (29.9)
Etiology of peritonitis			0.326
Perforation	49 (71.0)	233 (76.6)
Ischemia or infarction	20 (29.0)	71 (23.4)
Postoperative complications	38 (55.1)	39 (12.8)	<0.001
Postoperative mortality (≤30 days after surgery)	24 (34.8)	11 (3.6)	<0.001
Hospital stay after surgery (day)	19.8±24.7	14.7±11.2	0.101

Variable	According to ECR		P-value
Variable	Recovery (n=40)	No recovery (n=29)	P-value
Age (yr)	75±14	72±13	0.159
Sex			0.888
Male	20 (50.0)	15 (51.7)
Female	20 (50.0)	14 (48.3)
Symptom onset timing			0.264
≥48 hr	18 (45.0)	17 (58.6)
Occurrence of shock before surgery	21 (52.5)	24 (82.8)	0.009
Comorbidity			0.679
Yes	37 (92.5)	26 (89.7)
ASA score			0.075
E3	13 (32.5)	4 (13.8)
≥E4	27 (67.5)	25 (86.2)
History of major abdominal surgery	3 (7.5)	4 (13.8)	0.393
Serum creatinine level (mg/dl)	1.6±0.3	2.9±1.6	<0.001
Albumin level (serum)			0.048
<3.5 g/dl	21 (52.5)	22 (75.8)
Source of peritonitis			0.985
Gastric or duodenal origin	16 (40.0)	11 (37.9)
Small bowel origin	8 (20.0)	6 (20.7)
Colon or rectal origin	16 (40.0)	12 (41.4)
Etiology of peritonitis			0.196
Perforation	26 (65.0)	23 (79.3)
Ischemia or infarction	14 (35.0)	6 (20.7)
Surgical method			0.661
Laparoscopy	27 (67.5)	21 (72.4)
Open	13 (32.5)	8 (27.6)
Postoperative complications	11 (27.5)	27 (93.1)	<0.001
Postoperative mortality (≤30 days after surgery)	3 (7.5)	21 (72.4)	<0.001
Septic shock with MOF		18
Anastomosis leakage → sepsis → MOF	2	1
Respiratory failure		2
Postoperative cardiac arrest	1
Day of hospital stay after surgery (day)	12.9±14.6	20.6±10.9	0.370

Variable	Number	Complication	P-value	Mortality	P-value
Age (yr)			0.989		0.640
<75	29	16 (55.2)		11 (37.9)
≥75	40	22 (55.0)		13 (32.5)
Sex			0.187		0.930
Male	35	22 (62.9)		12 (34.3)
Female	34	16 (47.1)		12 (35.3)
Onset (hr)			0.404		0.356
<48	34	17 (50.0)		10 (29.4)
≥48	35	21 (60.0)		14 (40.0)
Shock			0.008		0.005
Yes	45	30 (66.7)		21 (46.7)
No	24	8 (33.3)		3 (12.5)
ASA score			<0.001		0.087
E3	17	6 (35.3)		3 (17.6)
E4	52	32 (61.5)		21 (40.4)
Comorbidity			0.263		0.938
Yes	63	36 (57.1)		22 (34.9)
No	6	2 (33.3)		2 (33.3)
History of previous surgery			0.359		0.190
Yes	7	5 (71.4)		4 (57.1)
No	62	33 (53.2)		20 (32.3)
Source of peritonitis			0.009		0.441
Gastric/duodenal	27	21 (77.8)		12 (44.4)
Small bowel	14	5 (35.7)		4 (28.6)
Colon/rectum	28	12 (42.9)		8 (28.6)
Etiology of peritonitis			0.032		0.276
Perforation	49	31 (63.3)		19 (38.8)
Infarction	20	7 (35.0)		5 (25.0)
Albumin (g/dl)			0.031		0.035
<3.5	43	28 (65.1)		19 (44.2)
≥3.5	26	10 (38.5)		5 (19.2)
Failure of ECR			<0.001		<0.001
Yes	29	27 (93.1)		21 (72.4)
No	40	11 (27.5)		3 (7.5)
Surgical method			0.819		0.139
Open	21	12 (57.1)		10 (47.6)
Laparoscopy	48	26 (54.2)		14 (29.2)

Variable	Postoperative complication		P-value	Postoperative mortality		P-value
Variable	aOR	95% CI	P-value	aOR	95% CI	P-value
Perforation (vs. infarction)	4.66	0.95–22.85	0.058
Failure of ECR (vs. ECR)	28.71	5.44–151.57	<0.001	32.37	7.74–135.40	<0.001

Table 1. Clinical characteristics and surgical outcomes by elevated preoperative creatinine status

Values are presented as mean±standard deviation or number (%).

PCE: preoperative creatinine elevation; ASA: American Society of Anesthesiologists.

Table 2. Clinical characteristics and outcomes by POD 3 ECR

Values are presented as mean±standard deviation or number (%).

POD: postoperative day; ECR: early creatinine recovery; PCE: preoperative creatinine elevation; ASA: American Society of Anesthesiologists; MOF: multiorgan failure.

Table 3. Univariate analyses of prognostic factors for postoperative complications and mortality

Values are presented as number (%).

ASA: American Society of Anesthesiologists; ECR: early creatinine recovery.

Table 4. Multivariable logistic regression for postoperative complications and mortality