Transthoracic echocardiography (TTE) has become an essential tool for hemodynamic evaluation. However, its effect on outcomes in sepsis-associated acute kidney injury (SA-AKI) remains unclear. This study aims to explore the association of TTE with the 28-day mortality in SA-AKI patients. MIMIC-IV database was used to identify patients with Sepsis whether they underwent TTE evaluation within 24 h of sepsis diagnosis. Propensity score matching (PSM) was employed to minimize confounding, and subgroup analyses were conducted to assess the impact of TTE across different AKI severity grades. Following PSM, 121 patients were included in each group (TTE vs. no TTE). The TTE group showed improved 28-day survival compared to the no TTE group (odds ratio = 0.80, 95% CI 0.21-0.81, p = 0.011). A subgroup analysis based on different AKI stages showed no significant association between TTE and the 28-day mortality in KIDGO stage 1 or 2 patients. However, for patients with KIDGO stage 3, those who underwent TTE evaluation had a significantly lower 28-day mortality rate (OR 0.81, 95% CI 0.68-0.96, p < 0.05). Patients with SA-AKI who underwent TTE had an improvement in 28-day mortality, with this effect being more pronounced in patients with KIDGO stage 3.© 2025. The Author(s).