Hyperchloremia and Prolonged Acidosis During Treatment for Pediatric Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis with a high anion gap secondary to ketonemia. Intravenous hydration fluids used in treatment can cause chloride overload, leading to hyperchloremic metabolic acidosis (HMA). The development of HMA can lead to the persistence of acidosis despite the resolution of ketonemia.

A total of 178 DKA episodes in 153 patients treated between January 2013 and October 2023 were included in the study. Creatine-based glomerular filtration rate and HbA1c value at admission and venous blood gas parameters (pH, actual bicarbonate, base deficit), anion gap, chloride-corrected bicarbonate, nonchloride base deficit, and sodium and chloride measured at 0, 2, 4, 6, 9, 12, 18 and 24 hours were evaluated.

Hyperchloremia was detected in 69.3% of participants and developed at a mean of 6.3 (±4.3) hours of treatment. The incidence of hyperchloremia increased with the duration of treatment; the rates were 8.4%, 51.3%, 65%, 76.2%, 75.5%, and 80% at 0, 6, 9, 12, 18, and 24 hours of treatment, respectively. The group with hyperchloremia had more severe acidosis, a higher HbA1c value, and a longer resolution time. At the 12th hour of treatment, acidosis continued based on pH and HCO 3 levels, whereas the hyperchloremia group exhibited a low anion gap (mean 12.8). At the 6th hour of treatment, the resolution rates were significantly lower in the hyperchloremia group based on the pH and HCO 3 levels but increased when assessed by chloride-corrected HCO 3 and anion gap.

During treatment of DKA, monitoring anion gap, blood ketones, and Cl - /Na + ratio or using regression equations in addition to routine acid-base parameters may help differentiate DKA from HMA and prevent prolonged intravenous treatment.