{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,17]],"date-time":"2026-01-17T04:17:08Z","timestamp":1768623428037,"version":"3.49.0"},"reference-count":18,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T00:00:00Z","timestamp":1749600000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: In diabetic ketoacidosis (DKA), absolute insulin deficiency and elevation of counter-regulatory hormones may cause osmotic diuresis and water and electrolyte loss, which may lead to dehydration and renal failure. Fluids with high Na content are preferred in the DKA fluid therapy algorithm due to the association of Na with \u03b2-Hydroxybutyrate (\u03b2-HB) and the renal excretion of Na-\u03b2-HB. However, these fluids may cause hyperchloremic metabolic acidosis due to their high chloride concentration. In the literature, base-excess chloride (BECl) has been suggested as a better approach for assessing the effect of chloride on acid\u2013base status. Our aim in this study was to investigate the effect of fluids with BECl values less than zero versus those with values equal to or greater than zero on the metabolic acid\u2013base status in the first 6 h of DKA. Methods: This retrospective study included DKA cases managed in the tertiary intensive care units of five hospitals in the last 10 years. Patients were divided into two groups according to the Na-Cl difference of the administered fluids during the first 6 h of treatment: Group I [GI, fluids with Na-Cl difference = 0, chloride-rich group] and Group II [GII, fluids with Na-Cl difference &gt; 32 mmol, chloride non-rich group]. Demographic data, blood gas analysis results, types and amounts of administered fluids, urea\u2013creatinine values, and urine ketone levels were recorded. Results: Thirty-five patients with DKA in the ICU were included in the study (GI; 22 patients, GII; 13 patients). There was no difference between the patients in the two groups in terms of age, gender, and LOS-ICU. According to the distribution of the administered fluids, the main fluid administered in GI was 0.9% NaCl, whereas in the GII, it was bicarbonate, Isolyte-S, and 0.9% NaCl. In GI, the chloride load administered was higher; the BECl level of the fluids was lower than in GII. At the end of the first 6 h, although sodium and strong ion gap values were similar, patients in GI were more acidotic due to iatrogenic hyperchloremia and, as a result, were more hypocapnic than GII. Conclusions: In conclusion, administering chloride-rich fluids in DKA may help reduce unmeasured anion acidosis. Still, risks cause iatrogenic hyperchloremic acidosis, which can hinder the expected resolution of acidosis and increase respiratory workload. Therefore, it is suggested that DKA guidelines be revised to recommend an individualized approach that avoids chloride-rich fluids and includes monitoring of metabolic parameters like Cl and BECl.<\/jats:p>","DOI":"10.3390\/jcm14124125","type":"journal-article","created":{"date-parts":[[2025,6,11]],"date-time":"2025-06-11T03:44:58Z","timestamp":1749613498000},"page":"4125","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Diabetic Ketoacidosis Fluid Therapy Algorithm in the Golden Hours: Iatrogenic Hyperchloremic Acidosis Instead of Unmeasured Anion Acidosis"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1352-7667","authenticated-orcid":false,"given":"Zeynep Tugce","family":"Sarikaya","sequence":"first","affiliation":[{"name":"Department of Anesthesiology and Reanimation, School of Medicine, Ac\u0131badem Mehmet Ali Ayd\u0131nlar University, 34752 Istanbul, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4464-4591","authenticated-orcid":false,"given":"Bulent","family":"Gucyetmez","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Reanimation, School of Medicine, Ac\u0131badem Mehmet Ali Ayd\u0131nlar University, 34752 Istanbul, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Duran","family":"Ozdemir","sequence":"additional","affiliation":[{"name":"General Intensive Care, Ac\u0131badem Bak\u0131rkoy Hospital, 34140 Istanbul, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Behiye","family":"Dogruel","sequence":"additional","affiliation":[{"name":"General Intensive Care, Ac\u0131badem Atakent Hospital, 34303 Istanbul, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aykut","family":"Ayyildiz","sequence":"additional","affiliation":[{"name":"General Intensive Care, Ac\u0131badem Maslak Hospital, 34457 Istanbul, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3007-8445","authenticated-orcid":false,"given":"Jozef","family":"Kesecioglu","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Medicine, University Medical Center, 3584 CX Utrecht, The Netherlands"},{"name":"General Intensive Care, Ac\u0131badem International Hospital, 34149 Istanbul, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lutfi","family":"Telci","sequence":"additional","affiliation":[{"name":"General Intensive Care, Ac\u0131badem International Hospital, 34149 Istanbul, Turkey"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,11]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Sieben, N., and Ramanan, M. 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Pharmacother."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/12\/4125\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:49:49Z","timestamp":1760032189000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/12\/4125"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,11]]},"references-count":18,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["jcm14124125"],"URL":"https:\/\/doi.org\/10.3390\/jcm14124125","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,6,11]]}}}