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Anemia is a risk factor for acute kidney injury (AKI) following cardiopulmonary bypass (CPB). Whether red blood cell (RBC) transfusion-enhanced hemoglobin levels contribute to low AKI rates remains unclear. We investigated the interaction between hemoglobin, RBC transfusion, and AKI after CPB. Hemoglobin trajectories within 72 h were analyzed using group-based trajectory analysis. Multivariable logistic analysis and inverse probability-weighted regression were adopted to evaluate the associations between hemoglobin and AKI in RBC and non-RBC transfusion subgroups. We analyzed 6226 patients’ data. In the transfusion subgroup, three hemoglobin trajectories were identified. The AKI incidence was lowest in the trajectory with the lowest hemoglobin level (trajectory 1, less transfusion), and it was comparable in trajectories 2 and 3 (20.7% vs. 32.7% vs. 29.4%,  p  &lt; 0.001, respectively). In four logistic models, the odds ratio for AKI with trajectory 1 as the reference ranged from 1.44 to 1.85 for trajectory 2 ( p  &lt; 0.001) and 1.45 to 1.66 for trajectory 3 ( p  &lt; 0.050). The average treatment effect on AKI was 5.6% ( p  = 0.009) for trajectory 2 and 7.5% ( p  = 0.041) for trajectory 3, with trajectory 1 as the reference. In the non-RBC transfusion subgroup, three approximately linear hemoglobin trajectories (9, 10, and 12 g/dL) were observed; however, both the crude and adjusted AKI incidence were similar within the three trajectories. In patients undergoing CPB, hemoglobin level &gt;9 g/dL was not associated with decreased AKI incidence in the subgroup without RBC transfusion. However, in patients with RBC transfusion, maintaining hemoglobin level &gt;9 g/dL by RBC transfusion was associated with increased AKI incidence.

Interaction of hemoglobin, transfusion, and acute kidney injury in patients undergoing cardiopulmonary bypass: a group-based trajectory analysis