Association between hyperchloremia and outcomes of children admitted to the pediatric intensive care unit (PICU) with diabetic ketoacidosis (DKA)

OBJECTIVES: Hyperchloremia is common in diabetic ketoacidosis (DKA), with prevalence reaching 90 %. However, its clinical impact in pediatric DKA remains unclear. This study aimed to assess the association between hyperchloremia and DKA recovery time, bicarbonate rise rate, and Pediatric Intensive Care Unit (PICU) stay, and to identify predictors of hyperchloremia. METHODS: This is a retrospective cohort study that included children under 13 years admitted to the PICU with DKA between 2018 and 2024. Patients with other acute acid-base disorders were excluded. Mann-Whitney test and Chi-square test were used as appropriate. Predictors of hyperchloremia were identified using binary logistic regression. Spearman correlation was used to assess associations between chloride levels and clinical outcomes. RESULTS: Among 162 patients, 132 (81.5 %) had hyperchloremia and 30 (18.5 %) had normochloremia. Hyperchloremic patients had longer DKA resolution time (16 vs. 8.25 h, p<0.001), slower bicarbonate rise (0.66 vs. 0.88 mmol/L/h, p=0.004), and longer PICU stay (26 vs. 18 h, p<0.001). Chloride levels significantly correlated with DKA resolution time, bicarbonate rise, and time to reach bicarbonate ≥15 mmol/L. Hyperchloremia was independently predicted by lower body weight (aOR: 0.9, 95 % CI: 0.83-0.98, p<0.001) and use of 0.9 % NaCl as intravenous fluid (aOR: 4.94, 95 % CI: 1.41-17.4, p<0.001). CONCLUSIONS: Hyperchloremia in children with DKA is associated with delayed recovery and prolonged PICU stay. Lower body weight and 0.9 % NaCl use increase hyperchloremia risk. More prospective studies are needed to assess alternative fluids containing different chloride concentrations.