SUN-638 - Does Ringer’s Lactate Improve Outcomes Compared With Normal Saline in Diabetic Ketoacidosis?: A Systematic Review & Meta Analysis

Background: Fluid resuscitation is a cornerstone of diabetic ketoacidosis (DKA) management, with 0.9% normal saline traditionally recommended as first-line therapy. However, its high chloride content may worsen hyperchloremic metabolic acidosis. Ringer’s lactate, a balanced crystalloid, has been proposed as an alternative due to its lower chloride concentration and buffering properties. We conducted a systematic review and meta-analysis to evaluate whether Ringer’s lactate improves clinical outcomes compared with normal saline in patients with DKA.

Methods: This systematic review was performed according to PRISMA 2020 guidelines and included randomized controlled trials and comparative observational studies comparing Ringer’s lactate with normal saline in adult or pediatric patients with DKA. PubMed, Embase, and Cochrane CENTRAL were searched from inception through November 2025. The primary outcome was time to DKA resolution. Secondary outcomes included resolution within 24 hours, intensive care unit (ICU) length of stay, total fluid administered, acute kidney injury (AKI), and hypokalemia. A random-effects model was used to calculate pooled mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CI).

Results: Five studies involving 300 patients (148 Ringer’s lactate, 152 normal saline) were included in the quantitative analysis. There was no significant difference between Ringer’s lactate and normal saline in time to DKA resolution (MD −1.33 hours; 95% CI −3.07 to 0.40; p=0.13; I²=27%). Similarly, no significant differences were observed in DKA resolution within 24 hours (RR 1.07; 95% CI 0.92–1.23), ICU length of stay (MD −1.77 days; 95% CI −6.94 to 3.41), total fluid administered (MD −95.46 mL; 95% CI −335.13 to 144.22), AKI (RR 0.83; 95% CI 0.37–1.88), or hypokalemia (RR 0.87; 95% CI 0.29–2.64). A trend toward faster resolution was observed in pediatric patients receiving Ringer’s lactate, although this did not reach statistical significance.

Conclusions: Ringer’s lactate appears to be a safe and effective alternative to normal saline for fluid resuscitation in DKA but does not demonstrate clear superiority in accelerating DKA resolution or improving major clinical outcomes. Both fluids remain appropriate options, and fluid
choice may be guided by clinical context, availability, and institutional practice. Larger randomized trials are needed to clarify potential subgroup-specific benefits.

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