AbstractAcute kidney injury (AKI) is a common and serious post‐operative complication of cardiac surgery. The value of a predictive biomarker is determined not only by its predictive efficacy, but also by how early this prediction can be made. For a biomarker of cardiac surgery‐associated AKI, this is ideally during the intra‐operative period. Therefore, in 82 adult patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB), we prospectively compared the predictive efficacy of various blood and urinary biomarkers with that of continuous measurement of urinary oxygen tension (UPO₂) at pre‐determined intra‐ and post‐operative time‐points. None of the blood or urine biomarkers we studied showed predictive efficacy for post‐operative AKI when measured intra‐operatively. When treated as a binary variable (≤ or > median for the whole cohort), the earliest excess risk of AKI was predicted by an increase in urinary neutrophil gelatinase‐associated lipocalin (NGAL) at 3 h after entry into the intensive care unit (odds ratio [95% confidence limits], 2.86 [1.14–7.21], p = 0.03). Corresponding time‐points were 6 h for serum creatinine (3.59 [1.40–9.20], p = 0.008), and 24 h for plasma NGAL (4.54 [1.73–11.90], p = 0.002) and serum cystatin C (6.38 [2.35–17.27], p = 0.001). In contrast, indices of intra‐operative urinary hypoxia predicted AKI after weaning from CPB, and in the case of a fall in UPO₂ to ≤10 mmHg, during the rewarming phase of CPB (3.00 [1.19–7.56], p = 0.02). We conclude that continuous measurement of UPO₂ predicts AKI earlier than plasma or urinary NGAL, serum cystatin C, or early post‐operative changes in serum creatinine.