{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,1]],"date-time":"2026-11-01T11:48:43Z","timestamp":1793533723857,"version":"4.5.0"},"reference-count":30,"publisher":"American Academy of Pediatrics (AAP)","issue":"11","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,11,1]]},"abstract":"\n OBJECTIVES<\/jats:title>\n To characterize serum chloride (Cl) burden during diabetic ketoacidosis (DKA), examine associations between Cl metrics and creatinine-defined acute kidney injury (CDAKI) and hospital length of stay (LOS), and to assess the relationship between initial beta-hydroxybutyrate (BHB) and initial serum creatinine (Scr).<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n We conducted a retrospective cohort study of children 1 to 20\u00a0years old with new-onset or established type 1 diabetes mellitus hospitalized for DKA from July 1, 2016, through July 31, 2022. Time-stamped serum electrolytes and renal function studies measured every 4\u00a0hours until DKA resolution. Multivariable logistic regression and time-to-event analyses evaluated associations across peak Cl, Cl normalization, CDAKI, incident CDAKI, and hospital LOS.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n A total of 364 patients accounting for 852 DKA encounters were included (mean age 13.3\u2009\u00b1\u20094.7\u00a0years, 52% male). The median baseline Cl was 105 mEq\/L (IQR, 100\u2013109) and the peak Cl was 118 mEq\/L (IQR, 114\u2013124). The median time to normalization was 50.4\u00a0hours. Additional normal saline boluses were independently associated with 37% lower hazard of Cl normalization (HR, 0.63; 95% CI, 0.46\u20130.87). Higher peak Cl was independently associated with CDAKI and incident CDAKI. CDAKI was in turn associated with longer hospitalization. Initial BHB was positively associated with initial Scr (Pearson r\u2009=\u20090.37; Spearman rho\u2009=\u20090.42; both P\u2009&lt;\u2009.001).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n Hyperchloremia is common during pediatric DKA treatment and is associated with CDAKI and longer hospitalization. Saline boluses were associated with chloride burden. Because initial BHB correlated with initial Scr, CDAKI at presentation should be interpreted cautiously. These findings highlight the need for prospective studies on chloride-sparing strategies in pediatric DKA.<\/jats:p>\n <\/jats:sec>","DOI":"10.1542\/hpeds.2026-009505","type":"journal-article","created":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T00:03:00Z","timestamp":1789344180000},"page":"911-919","source":"Crossref","is-referenced-by-count":1,"title":["Serum Chloride Trajectories and Acute Kidney Injury in Children With Diabetic Ketoacidosis"],"prefix":"10.1542","volume":"16","author":[{"given":"Rashed A.","family":"Hasan","sequence":"first","affiliation":[{"name":"1Department of Pediatrics, Hurley Medical Center, Flint, Michigan"},{"name":"2Michigan State University, East Lansing, Michigan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael S. D.","family":"Agus","sequence":"additional","affiliation":[{"name":"3Medical Intensive Care Unit, Boston Children\u2019s Hospital, Boston, Massachusetts"},{"name":"4Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"417","published-online":{"date-parts":[[2026,9,14]]},"reference":[{"issue":"suppl 27","key":"2026103120015828400_r1","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1111\/pedi.12701","article-title":"ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state","volume":"19","author":"Wolfsdorf","year":"2018","journal-title":"Pediatr Diabetes."},{"issue":"suppl 12","key":"2026103120015828400_r2","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1111\/j.1399-5448.2009.00569.x","article-title":"Diabetic ketoacidosis in children and adolescents with diabetes","volume":"10","author":"Wolfsdorf","year":"2009","journal-title":"Pediatr Diabetes."},{"issue":"15","key":"2026103120015828400_r3","doi-asserted-by":"crossref","first-page":"1566","DOI":"10.1001\/jama.2012.13356","article-title":"Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults","volume":"308","author":"Yunos","year":"2012","journal-title":"JAMA."},{"issue":"12","key":"2026103120015828400_r4","doi-asserted-by":"crossref","first-page":"1897","DOI":"10.1007\/s00134-014-3505-3","article-title":"Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS","volume":"40","author":"Shaw","year":"2014","journal-title":"Intensive Care Med."},{"issue":"3","key":"2026103120015828400_r5","doi-asserted-by":"crossref","first-page":"726","DOI":"10.1172\/JCI110820","article-title":"Regulation of renal blood flow by plasma chloride","volume":"71","author":"Wilcox","year":"1983","journal-title":"J Clin Invest."},{"issue":"9","key":"2026103120015828400_r6","doi-asserted-by":"crossref","first-page":"1938","DOI":"10.1097\/CCM.0000000000001161","article-title":"Acute kidney injury in critical illness study G Association of Hyperchloremia with Hospital Mortality in critically ill septic patients","volume":"43","author":"Neyra","year":"2015","journal-title":"Crit Care Med."},{"issue":"4","key":"2026103120015828400_r7","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1007\/s13312-018-1274-8","article-title":"Predictors and outcome of acute kidney injury in children with diabetic ketoacidosis","volume":"55","author":"Baalaaji","year":"2018","journal-title":"Indian Pediatr."},{"issue":"3","key":"2026103120015828400_r8","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1007\/s00467-023-06152-0","article-title":"The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis","volume":"39","author":"Hay","year":"2024","journal-title":"Pediatr Nephrol."},{"issue":"5","key":"2026103120015828400_r9","doi-asserted-by":"crossref","first-page":"e3831","DOI":"10.1002\/dmrr.3831","article-title":"Fluid resuscitation with balanced electrolyte solutions results\u00a0in faster resolution of diabetic ketoacidosis than with\u00a00.9% saline in adults - 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