Ketoacidosis diagnosis

What sample is needed for the diagnosis of Ketoacidosis?

1. Blood is needed to prepare the serum.
2. A urine sample may also be used.

What are the indications for Ketoacidosis?

1. Ketone bodies are advised in patients with diabetes mellitus.
2. It can be advised in case of uncontrolled diabetes mellitus.
3. Ketoacidosis is associated with alcoholism, starvation,  and a high-protein diet.

How will you define Ketoacidosis?

1. Glycolysis is inhibited in ketoacidosis, while glycogenolysis and gluconeogenesis are stimulated.
2. There is hyperglycemia, deranged acid balance, and electrolyte imbalance.
3. It is acute life-threatening metabolic acidosis due to uncontrolled diabetes mellitus ( usually type 1 and infrequently type 2).
4. This condition occurs when decompensation results from other diseases, insulin deficiency, and excess hormone-producing glucose.

What is another definition of Ketoacidosis?

1. A lack of insulin leads to the metabolism of protein and fat to provide energy. Normally, energy is supplied by carbohydrates.
2. Ketone bodies and other metabolic acids accumulate in the blood.
3. Accumulation of ketone bodies (acetone, acetoacetate, and β-hydroxybutyrate) is the principal feature of diabetic ketoacidosis.
4. There is hyperglycemia. Ketones and glucose appear in the urine.
5. There is hyperosmolarity.
6. Low pH.
7. Patients have lethargy and may go into a coma.

How will you discuss the Pathophysiology of Ketoacidosis?

1. Acetyl coenzyme A (acetyl-CoA) from the  TCA (Tricarboxylic acid cycle) is at the junction of glucose, protein, and fat metabolism.
2. Free fatty acids enter the TCA cycle as acetyl-CoA. It changes to acetoacetyl-CoA.
3. It then forms HMG-CoA (3-hydroxy-3-methylglutaryl CoA).
4. This HMG-CoA can be metabolized to cholesterol or converted to acetoacetate.
5. Acetoacetate can change into:
   1. Spontaneous decarboxylation to acetone in the lungs.
   2. Or Enzymatic reduction to β-hydroxybutyrate.
   3. Acetoacetate and β-hydroxybutyrate are called keto acids or ketone bodies.
   4. Ketone acids are the energy source for the brain, kidneys, and cardiac muscles.
   5. Kidneys excrete excess acetoacetate and β-hydroxybutyrate, with a loss of Na⁺ and K⁺.
   6. Loss of Na⁺ and K⁺ from the kidneys leads to retention of the H⁺ ions.

6. In diabetes mellitus, low insulin levels mobilize fatty acids from triglycerides.
7. Fatty acid degradation increases as fatty acids become the cell’s major energy source.
8. Increased fatty acid metabolism increases the levels of acetyl-CoA.
   1. This excess Acetyl CoA enters the TCA cycle to produce energy.
   2. Still, some of it forms ketone bodies (keto acids) and leads to ketosis.
   3. Increased production of keto acids utilizes HCO3^– and lowers the blood pH (acidosis).
9. This mechanism occurs during starvation, except that there is hypoglycemia rather than hyperglycemia.
10. The liver takes up long-chain fatty acids.
    1. In the liver, they are reesterified to triglycerides and stored.
    2. Or these are converted to very low-density lipoprotein and return to the blood.
11. Infants develop ketonuria earlier than adults after decreased food intake.

What are the findings in uncontrolled diabetes mellitus?

1. Low insulin level leads to:
   1. Increased lipolysis.
   2. Decreased reesterification.
   3. There are increased plasma-free fatty acids.
2. Insulin and glucagon ratio changes.
   1. This ratio is changed and enhances fatty acid oxidation.
   2. It increases ketone body formation in the liver and decreases peripheral tissue metabolism, resulting in blood accumulation.
   3. There is an accumulation of acetoacetate, a ketone body, in the blood.

What are the signs and symptoms of diabetic ketoacidosis?

There may be :

1. A cough.
2. Fever.
3. Chills.
4. Chest pain.
5. Arthralgia.
6. Dyspnoea.
7. Tachycardia.
8. Hypotension.
9. Hypothermia.

What are the causes of ketone body formation?

1. Starvation.
2. Frequent vomiting.
3. Diabetes mellitus.
4. Glycogen storage disease (Von Gierke disease).
5. During pregnancy.

How will you diagnose diabetic ketoacidosis?

1. The glucose level may range from 300 to 500 mg/dL.
2. Ketone bodies are beta-hydroxybutyric acid, acetoacetic acid, and acetone.
   • These are produced during gluconeogenesis due to increased fatty acid oxidation, which produces acetyl-CoA.
   • An excessive concentration of ketone bodies in the blood is called ketonemia.
   • When there is increased excretion in the urine, it is called ketonuria.
3. Electrolytes show :
   1. Decreased Sodium.
   2. Increased Potassium.
   3. The anion gap is increased.
   4. Total CO2 decreased.
4. Blood gases show:
   1. pH decreased.
   2. Metabolic acidosis.
   3. Bicarbonates are decreased.

What are the differentiating points of Ketoacidosis (Diabetic ketosis)?

How will you detect ketone bodies in the urine (Ketonuria)?

How will you discuss the sodium nitroprusside reaction?

1. This reaction gives lavender color.
2. This is very sensitive, ten times more for acetoacetate than with acetone. It detects acetoacetate and acetone.
3. It does not react with β-hydroxybutyrate.

How will the Sodium nitroprusside react with ketone bodies?

1. Take 0.5 to 1.0 grams (pea-size) of well-mixed nitroprusside reagent in a test tube or on the tile.
2. Add a drop of a fresh urine sample to the reagent (Nitroprusside).
3. After one minute, check the color.
4. Results reported as:
   1. No color change = Ketones negative.
   2. Slight purple color = Ketone positive (+).
   3. Moderate purple color = Ketone positive (++).
   4. Dark purple color = Ketone positive (+++).