Seventy-eight patients undergoing total knee arthroplasty for knee cartilage wear or rheumatoid arthritis were randomized to receive either remimazolam (RMMZ; n=39) or sevoflurane (SEVI; n=39). The primary outcome of interest was the incidence of acute kidney injury after 2 days. Secondary outcomes of interest included intraoperative outcomes such as blood pressure, heart rate, intraoperative medication use, blood loss, and emergence time. Postoperative outcomes such as length of stay, adverse events, time to eye-opening, time to an Aldrete score ≥9 were also assessed. Remifentanil, vasodilator administration, and sedative administration were significantly lower in the SEVO group, whereas inotropic administration was lower in the RMMZ group. Eye open rate, extubation time, and time of OR exit were significantly better in the RMMZ group than the SEVO group. The incidence of acute kidney injury was similar between the two groups.