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Increased serum creatinine(SCr)was common after cardiac surgery and associated with poor outcomes.However,the prognostic role of postoperative SCr level measured on the morning of the first day was unclear in middle-aged and aged patients with rheumatic heart disease(RHD)undergoing valve replacement sur-gery(VRS).Methods Consecutive middle-aged and aged patients(age≥45 years)diagnosed with RHD under-going at least one valve replacement were enrolled.Patients were routinely taken into the intensive care unit(ICU)for special care within 1 hour after VRS.SCr was measured at ICU admission and on the first day morning(within 24 hours).Association of postoperative SCr level with in-hospital and one-year mortality was analyzed.Results 3919 patients were finally included and divided into 4 groups according to the quartiles of postopera-tive SCr level on the first day morning:＜1.0 mg/dL(n=1064),1.0-1.2 mg/dL(n=892),1.2-1.5 mg/dL(n=956)and≥1.5 mg/dL(n=1007).SCr level measured on the first day morning following surgery was an independent predictor for in-hospital mortality(adjusted OR:3.42,95％CI:2.52-4.63,P＜0.001)and 1-year mortality(adjust-ed HR:2.99,95％CI:2.32-3.86,P＜0.001).SCr level measured at this time had a greater predictive power for in-hospital mortality than that measured at the time of ICU admission after surgery(P＜0.001).Cumulative one-year mortality was significantly higher in patients with upper postoperative SCr quartiles on the first day morning(Log-rank:125.75,P＜0.001).Conclusions Postoperative SCr level measured on the first day morning could serve as an early and powerful prognostic marker for in-hospital and one-year mortality in middle-aged and aged RHD pa-tients undergoing VRS.Attention should be paid to RHD patients with increased postoperative SCr level within 24 hours after surgery.