Objective To investigate the predictive value of geriatric nutritional risk index (GNRI) combined with serum uric acid (SUA) for the prognosis of elderly patients with acute respiratory distress syndrome (ARDS). Methods The clinical data of 159 ARDS patients admitted to our hospital between January 2018 and September 2021 were collected and retrospectively analyzed. According to their 28-day outcomes, they were divided into survival (n=116) and death (n=43) groups. Based on their oxygenation index, they were assigned into mild (n=35), moderate (n=70) and severe (n=54) groups. Clinical data of the patients were collected, GNRI values were calculated, and SUA levels were detected. The data were analyzed by SPSS statistics 22.0. Receiver operating characteristic (ROC) curve and Kaplan-Merier curves were used to analyze the prognostic values of GNRI and SUA for elderly patients with ARDS. Results The survival and death patients differed in oxygenation index, severity of illness, and scores of Acute Physiology and Chronic Health Evaluation Ⅱ and Sequential Organ Failure Assessment (all P<0.05). The deceased patients had significantly lower GNRI level [(77.42±7.06) vs (88.17±10.39) points] and higher SUA level [(544.46±63.97) vs (469.70±45.69) μmol/L] than the survival group (both P<0.05). The severe ARDS patients had significantly lower GNRI level [(81.37±10.14) vs (90.17±10.69) and (85.81±10.15) points; both P<0.05] and higher SUA level [(514.05±61.52) vs (458.84±58.10) and (486.84±54.64)μmol/L; both P<0.05], when compared with the mild and moderate patients. Pearson correlation analysis revealed that oxygenation index was positively correlated with GNRI (r=0.412, P<0.01) and negatively with SUA (r=-0.403, P<0.01). ROC curve analysis showed that GNRI combined with SUA had an area under curve of 0.892, a sensitivity of 83.72% and a specificity of 81.90% for predicting the outcome of ARDS patients, which was superior to single index test. Kaplan-Meier curve analysis indicated that the 28-day mortality rate in the patients of GNRI≥83.07 points and SUA≤493.13 μmol/L, respectively, was lower in those with GNRI<83.07 points and with SUA>493.13 μmol/L (P<0.05). Conclusion GNRI and SUA are closely associated with disease severity and prognosis in elderly patients with ARDS, and the 2 indicators combined together have greater predictive value for the prognosis of elderly patients with ARDS.