To examine the association between abdominal aortic calcium score (AACS), quantified using the Agatston scoring system, and postoperative renal function in patients undergoing radical nephrectomy (RN) for malignant renal pathologies.

We conducted a retrospective analysis of 114 patients who underwent RN at our institution between 2007 and 2019. Inclusion required a noncontrast computed tomography (CT) scan within 1 year before or after surgery, and a baseline estimated glomerular filtration rate (eGFR) of ≥60 mL/min/1.73 m². AACS was quantified using the Agatston scoring system. The primary outcome was the development of chronic kidney disease (CKD), defined as a postoperative eGFR <60 mL/min/1.73 m² at 12 months. Multivariable linear regression models were used to evaluate associations between AACS and postoperative renal function, adjusting for age, hypertension, diabetes, and pre‑operative eGFR.

Patients who developed CKD at 12 months postoperatively were older (mean: 64.6 vs 58.6 years, P = .009). While no significant differences were observed in body mass index (BMI), comorbidities, or renal artery calcium scores, patients who developed CKD had significantly higher median AACS compared to those who did not (1274.5 [IQR: 158.8-3938.2] vs 39.1 [IQR: 0.0-1297.1], P = .009). In the multivariable analyses, higher AACS was independently associated with greater eGFR decline from baseline to 12 months, whereas AACS was not independently associated with absolute 12-month eGFR.

Elevated AACS was associated with worse postoperative renal outcomes after RN and, in adjusted analyses, independently associated with greater renal function decline. Incorporating AACS into preoperative assessment may improve risk stratification and patient counseling.