Efficacy of Balanced Solutions Versus Normal Saline on Diabetic Ketoacidosis Resolution

Introduction: Diabetic ketoacidosis (DKA) is a serious life-threatening complication. Current guidelines recommend normal saline (NS), however emerging evidence suggests that balanced crystalloids, such as Lactated Ringer’s (LR) may be more effective in the acute management of DKA given the risk of hyperchloremic non-anion gap metabolic acidosis and acute kidney injury with NS. The purpose of this study was to compare the efficacy of LR versus NS in the management of DKA.


Methods: This was a multi-site, retrospective, observational study at a 3,260-bed community teaching hospital system. Patients admitted between August 1, 2022 to August 31, 2024 with DKA and treated with either LR or NS were evaluated. Patients were excluded if they were transferred from an outside hospital, had end-stage renal disease, or euglycemic DKA. The primary outcome was time to DKA resolution. Secondary outcomes include time to anion gap closure, discontinuation of maintenance fluid, duration of insulin infusion, incidence of hyperchloremic non-anion gap metabolic acidosis, acute kidney injury, hypokalemia, ICU and hospital length of stay (LOS).


Results: A total of 1,738 patients were screened, with 152 patients included in the final analysis. Baseline characteristics were similar between the two groups, except higher rates of severe DKA in the LR group (59% vs 24%; p< 0.001) and elevated markers of DKA severity: pH (7.13 vs 7.24; p< 0.001), anion gap (33 mmol/L vs 23 mmol/L; p< 0.001), and beta-hydroxybutyrate (8.6 mmol/L vs 4.8 mmol/L; p< 0.001). Lactated Ringer’s was associated with shorter time to DKA resolution (20.5 hr vs 24.1 hr; p=0.022). Secondary outcomes were similar between the groups except time to anion gap closure was faster in the LR group (16.4 hr vs 20.3 hr; p=0.004), and ICU LOS higher in LR group (51.3 hr vs 37.5 hr; p=0.015).


Conclusions: Lactated Ringer’s was associated with a faster time to DKA resolution compared with normal saline. The findings of this study suggest that LR may be the preferred choice of fluid therapy in the management of DKA, but larger prospective studies are warranted to validate the findings of this study.