Managing diabetic ketoacidosis (DKA) in patients with chronic kidney disease (CKD) is complex due to altered glucose metabolism, insulin sensitivity, and medication clearance. Current guidelines primarily address patients with normal or mildly impaired renal function, leaving a gap for those with advanced CKD. This study evaluated outcomes and management of DKA in patients with varying degrees of CKD.

In this retrospective study (2005–2023), adults hospitalized with DKA were stratified by baseline eGFR: ≥60, 30–59, and <30 mL/min/1.73m². Primary outcome was length of hospital stay; secondary outcomes included one-year mortality, in-hospital and 30-day mortality and DKA recurrence.

Of 318 patients, 277 had eGFR ≥60, 24 had 30-59, and 17 had <30. Patients with advanced CKD (eGFR <30) exhibited significantly prolonged median LOS (9 vs. 4 days; P=0.002) and higher 1-year mortality (52.9% vs. 10.1%; P<0.001). In multivariate analysis, advanced CKD remained a robust independent predictor of a 2.3-fold increase in LOS (IRR 2.29, P=0.002), a 3.5-fold increased risk of 1-year mortality (HR 3.57, P=0.002), and a more than 3-fold higher risk of DKA recurrence (SHR 3.38, P=0.007). These findings were further validated in the propensity-matched cohort. Notably, higher rates of fluid administration were independently associated with shorter LOS (P=0.012) across all groups.

Advanced CKD is a robust independent risk factor for mortality, recurrence, and prolonged hospitalization in DKA patients. Initial aggressive fluid resuscitation was not associated with adverse clinical outcomes, suggesting its safety in this high-risk population.