AIM: Postoperative acute kidney injury (AKI) is a serious complication commonly occurring after colorectal cancer surgery, primarily associated with prolonged hospitalization and poor prognosis. Metabolic syndrome (MetS) is accompanied by chronic inflammation, insulin resistance, and subclinical renal dysfunction—factors that could augment susceptibility to AKI in patients under surgical stress. This study aims to investigate the incidence and risk factors of postoperative AKI in colorectal cancer patients with MetS and provide a reference for perioperative risk management.

METHODS: In this retrospective cohort study, 209 patients with MetS who underwent radical resection for colorectal cancer at Ezhou Central Hospital from January 2023 to December 2025 were consecutively enrolled. According to whether AKI occurred after surgery, the patients were divided into AKI group (n = 63) and non-AKI group (n = 146). Demographic data, metabolic indicators, inflammatory markers, and surgery-related variables were collected. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors of AKI, and a predictive model was constructed. The model’s performance was evaluated by analyzing the area under the curve (AUC) and the calibration curve.

RESULTS: Univariate analysis showed that fasting plasma glucose, 2-hour postprandial blood glucose, systolic blood pressure, diastolic blood pressure, components of metabolic syndrome, preoperative neutrophil-to-lymphocyte ratio (NLR), intraoperative blood loss, hypoalbuminemia, and intraoperative hypotension were significantly associated with AKI (p < 0.05). Multivariate analysis showed that diastolic blood pressure (odds ratio [OR] = 1.071, 95% confidence interval [CI]: 1.033–1.109), preoperative NLR (OR = 2.832, 95% CI: 1.381–5.804), intraoperative blood loss (OR = 1.040, 95% CI: 1.026–1.054), and intraoperative hypotension (OR = 3.499, 95% CI: 1.276–9.592) were independent risk factors for postoperative AKI. The AUC of the predictive model was 0.86, indicating good calibration.

CONCLUSIONS: Colorectal cancer patients with MetS are at an increased risk of postoperative AKI. Elevated diastolic blood pressure, a higher preoperative NLR, increased intraoperative blood loss, and episodes of intraoperative hypotension are independent risk factors of AKI. Therefore, optimizing perioperative blood pressure control, assessing the inflammatory status, adopting more delicate surgical techniques, and ensuring vigilant hemodynamic monitoring are essential strategies to reduce the risk of AKI in these patients.