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Hypochloraemia is associated with 28-day mortality in patients with septic shock: a retrospective analysis of a multicentre prospective registry
  1. Min Sung Lee1,
  2. Tae Gun Shin2,
  3. Won Young Kim3,
  4. You Hwan Jo4,
  5. Yoon Jung Hwang5,
  6. Sung Hyuk Choi6,
  7. Taeho Lim7,
  8. Kap Su Han8,
  9. JongHwan Shin9,
  10. Gil Joon Suh1,
  11. Kyung Su Kim1,
  12. Gu Hyun Kang10
  13. for the Korean Shock Society (KoSS) investigators
  1. 1Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
  2. 2Emergency Medicine, Samsung Medical Center, Seoul, Republic of Korea
  3. 3Emergency Medicine, Asan Medical Center, Seoul, Republic of Korea
  4. 4Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
  5. 5Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
  6. 6Emergency Medicine, Guro Hospital, Korea University Medical Center, Seoul, Republic of Korea
  7. 7Emergency Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
  8. 8Emergency Medicine, College of Medicine Korea University, Seoul, Republic of Korea
  9. 9Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
  10. 10Emergency medicine, Hallym University College of Medicine, Seoul, Republic of Korea
  1. Correspondence to Kyung Su Kim, Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; kanesu{at}


Objectives Hyperchloraemia is associated with poor clinical outcomes in sepsis patients; however, this association is not well studied for hypochloraemia. We investigated the prevalence of chloride imbalance and the association between hypochloraemia and 28-day mortality in ED patients with septic shock.

Methods A retrospective analysis of data from 11 multicentre EDs in the Republic of Korea prospectively collected from October 2015 to April 2018 was performed. Initial chloride levels were categorised as hypochloraemia, normochloraemia and hyperchloraemia, according to sodium chloride difference adjusted criteria. The primary outcome was 28-day mortality. A multivariate logistic regression model adjusting for age, sex, comorbidities, acid-base state, sepsis-related organ failure assessment (SOFA) score, lactate and albumin level was used to test the association between the three chloride categories and 28-day mortality.

Results Among 2037 enrolled patients, 394 (19.3%), 1582 (77.7%) and 61 (3.0%) patients had hypochloraemia, normochloraemia and hyperchloraemia, respectively. The unadjusted 28-day mortality rate in patients with hypochloraemia was 27.4% (95% CI, 23.1% to 32.1%), which was higher than in patients with normochloraemia (19.7%; 95% CI, 17.8% to 21.8%). Hypochloraemia was associated with an increase in the risk of 28-day mortality (adjusted OR (aOR), 1.36, 95% CI, 1.00 to 1.83) after adjusting for confounders. However, hyperchloraemia was not associated with 28-day mortality (aOR 1.35, 95% CI, 0.82 to 2.24).

Conclusion Hypochloraemia was more frequently observed than hyperchloraemia in ED patients with septic shock and it was associated with 28-day mortality.

  • intensive care
  • death/mortality
  • infection
  • research
  • clinical
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  • Handling editor Roland Merchant

  • Contributors MSL conceived the idea and drafted the manuscript. KSK helped to design the study and advised for details. TGS, WYK, YHJ, YJH, SHC, TL, KSH, JHS, GJS and GHK prepared and collected data. MSL and KSK analysed the data and performed the statistical analysis. GJS and TGS supervised the whole study process. KSK helped to revise the manuscript. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Participating the KoSS registry was approved by the institutional review boards (IRBs) of the individual participating hospitals and informed consent was obtained according to local IRB policy (IRB No. 1408-003-599). IRB No. of each individual hospitals are as follows; Seoul National University Hospital (J-1408-003-599), Samsung Medical Centre (SMC2015-09-057-057), Asan Medical Centre (S2015-1918-0002), Seoul National University Bundang Hospital (B-1409/266–401), Severance Hospital (Yonsei University College of Medicine) (4-2015-0929), Gangnam Severance Hospital (Yonsei University College of Medicine) (3-2015-0227), Korea University Kuro Hospital (KUGH15358-001), Hanyang University Hospital (HYUH 2015-11-013-022), Korea University Anam Hospital (HRPC2016-184), Seoul National University Boramae Hospital (IRB-16-2014-36), Gangnam Sacred Heart Hospital (2015-11-142). Retrospective analysis of the KoSS data for this study was also approved by the IRB (No. 1807-101-960).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. According to local IRB policy, collected data should not be viewed or leaked except for authorised researchers in order to protect the personal information of the subjects studied.

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