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Ketoacidosis diagnosis, Diabetic Ketoacidosis

May 8, 2024Chemical pathologyLab Tests

Table of Contents

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  • Ketoacidosis diagnosis
        • What sample is needed for the diagnosis of Ketoacidosis?
        • What are the indications for Ketoacidosis?
        • How will you define Ketoacidosis?
        • What is another definition of Ketoacidosis?
      • How will you discuss the Pathophysiology of Ketoacidosis?
        • What are the findings in uncontrolled diabetes mellitus?
        • What are the signs and symptoms of diabetic ketoacidosis?
        • What are the causes of Ketone Bodies Formation?
        • How will you diagnose diabetic ketoacidosis?
        • What are the differentiating points of Ketoacidosis (Diabetic ketosis)?
        • How will you detect ketone bodies in the urine (Ketonuria)?
        • Discuss sodium nitroprusside reaction?
        • How will the Sodium nitroprusside react with ketone bodies?
      • Questions and answers:

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.
    1. The advice in case of uncontrolled diabetes mellitus.
    2. Ketoacidosis is associated with alcoholism, starvation,  and a high-protein diet.

How will you define Ketoacidosis?

  1. There is inhibition of glycolysis 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 by other diseases, insulin deficiency, and excess hormone-producing glucose.

What is another definition of Ketoacidosis?

  1. A lake 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 at Acetyl CoA. It changes to acetoacetyl CoA.
  3. It then forms HMG-CoA (3-hydroxy-3-methylglutaryl CoA).
    1. This HMG-CoA can be metabolized to cholesterol or converted to acetoacetate.
  4. 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. Ket acids are the energy source for the brain, kidneys, and cardiac muscles.
    5. Kidneys excrete an excess of  Acetoacetate and β-hydroxybutyrate with a loss of Na+ and K+.
    6. Loss of Na+ and K+ from kidneys leads to retention of the H+ ions.
Ketones bodies and Diabetes Mellitus

Ketones bodies formation and Diabetes Mellitus

  1. In diabetes mellitus, low insulin levels mobilize fatty acids from triglycerides.
  2. Fatty acid degradation increases as it becomes the cell’s major energy source.
  3. Increased fatty acid metabolism gives rise to increased molecules of acetyl CoA.
    1. This excess Acetyl CoA enters the TCA cycle to produce energy.
    2. Still, some of it forms ketone bodies and ketosis (keto acids).
    3. Increased production of keto acids utilizes HCO3– and lowers the blood pH (acidosis).
  4. This mechanism occurs in starvation, except there is hypoglycemia instead of hyperglycemia.
  5. 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.
  6. Infants have earlier ketonuria than adults after decreased food intake.
ketone bodies formation in diabetic and complications

ketone-bodies formation in diabetes and complications

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 leads to increased ketone body formation in the liver and decreased peripheral tissue metabolism, which leads to blood accumulation.
    3. There is an accumulation of acetoacetate ketone bodies in the blood.
ketone bodies ratio in diabetes mellitus

ketone bodies ratio in diabetes mellitus

Ketone bodies in diabetic patient

Ketone bodies in a diabetic patient

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 Bodies 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 to 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)?

Test Lab findings/Clinical presentation
  • Glucose
  • Blood glucose level = 300 to 500 mg/dL (250 to 600 mg/dL)
  • Plasma insulin
  • Low to zero
  • Ketones
  • Positive (Acetone, Beta-hydroxybutyric acid, and acetoacetic acid)
  • Plasma acetone
  • Positive in diluted plasma
  • Serum BUN
  • Mild increase
  • Serum lactate
  • 2 to 3 mmol/L
  • Electrolytes
  1. Sodium Decreased
  2. K+ increased (normal, increased, or low)
  3. HCO3+ decreased (<15 meq/L)
  4. Anion gap = increased (>12 meq/L)
  5. Serum magnesium = Normal or increased
  6. Serum osmolality = <320 mOsm/L
  • Blood gases
  1. pH decreased (<7.30)
  2. Total CO2 decreased
  • Clinical signs and symptoms
  1. Age = It is seen in the Younger age group
  2. Fever = Normal or low
  3. Type of diabetes = Usually type 1
  4. Onset = It is acute/subacute
  5. H/O diabetes = Usually present
  6. Acetone breath = It is Present
  7. H/O prodrome = Usually <1 day
  8. Precipitating factor = Infection is seen in 30% of the cases
    1. Unknown in 20% of the cases
  9. Acetone breath smell = It is usually present
  10. Kussmaul respiration = It is present
  11. Dehydration = Less frequent
  12. Abdominal pain = It is usually present
  13. Changes in mental status = It is moderate
  14. Neurological presentation = It is rare
  15. Renal diseases = It is seen in 15% of the cases
  16. Cardiovascular diseases = It is seen in 15% of the cases
  17. H/O thrombosis = It is rarely seen
  18. Mortality =  It is <10%

 

Diabetic ketoacidosis

Diabetic ketoacidosis

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

Discuss 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.
Sodium nitroprusside reaction for ketone bodies

Sodium nitroprusside reaction for ketone bodies

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 (+++).
Ketoacidosis diagnosis: Ketones test by nitroprusside reaction

Ketoacidosis diagnosis: Ketones test by nitroprusside reaction

Questions and answers:

Question 1: How will you diagnose ketone bodies?
Show answer
Ketone bodies can be diagnosed by sodium nitroprusside test.
Question 2: What will be the pH level in diabetic ketoacidosis?
Show answer
pH will be <7.3 in diabetic ketoacidosis.
Possible References Used
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