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To investigate differences in sex-specific computed tomography abdominal fat and skeletal muscle (SM) characteristics between type 2 diabetic retinopathy (DR) patients with and without diabetic kidney disease (DKD). This retrospective study included type 2 diabetes mellitus DR patients with/without DKD between January 2019 and July 2021. Visceral adipose tissue (VAT), subcutaneous adipose tissue, perirenal adipose tissue (PAT), intramuscular adipose tissue, and SM areas were measured. Univariate and multivariate logistic regression analyses were used to analyze risk factors for DKD. Correlation and multiple linear regression analyses were used to clarify the association between computed tomography abdominal fat, SM characteristics, and cystatin C. Two hundred and forty-one patients were enrolled and divided into DR with DKD group (n = 142) and DR without DKD group (n = 99). In men, hypertension (OR: 5.21; 95%CI: 1.93–14.05; p = 0.001), diastolic pressure (OR: 1.07; 95%CI: 1.01–1.12; p = 0.011), hemoglobin (OR: 0.94; 95%CI: 0.92–0.97; p < 0.001) and PAT attenuation value (OR: 1.09; 95%CI: 1.01–1.17; p = 0.026) were independent risk factors for DKD progression in DR patients, while the VAT index (VATI) (OR: 1.03; 95%CI: 1.01–1.05; p = 0.014) was an independent risk factor for female patients. Multiple linear regression analysis revealed significant correlations between hypertension (β = 0.22, p = 0.002) and hemoglobin (β = -0.53, p < 0.001) with cystatin C in men, and a significant correlation between VATI and cystatin C (β = 0.35, p = 0.037) in women after adjustment for confounders. Female DR patients with elevated VAT level may suffer from a higher risk of DKD than that in male patients. [ABSTRACT FROM AUTHOR]