Urine for ketones (Ketonuria)

What sample is needed for Urine for ketones?

1. This is done in the urine.
2. This test can also be done on blood (serum or plasma).

What are the precautions for Urine ketones?

1. Keep the urine refrigerated and in closed containers.
2. Avoid loss due to evaporation and bacterial action.
3. Keep the blood also refrigerated.
4. Some of the drugs give false-positive results, e.g.
   1. Phenothiazine.
   2. Ether and chloroform.
   3. Metformin.
   4. Captopril.
   5. Insulin.
   6. Levodopa.
   7. Penicillamine.
   8. Isopropyl alcohol.
   9. Valproic acid.
   10. Aminosalicylic acid.
5. The false-negative result is seen in the following:
   1. When urine is kept at room temperature for a long time due to the loss of ketones in the air.
   2. Aspirin.
   3. Phenazopyridine.

What are the indications for Urine ketones?

1. It is advised in diabetic patients for the early diagnosis of ketoacidosis.
   1. Ketones are used to judge the acidosis’s severity and monitor the treatment response.
2. Testing of ketonuria in diabetetics:
   1. To evaluate the diabetic patient in a coma.
   2. To monitor people with diabetes who are on oral hypoglycemic drugs.
   3. Check when the patient is switched from insulin to oral hypoglycemics; ketonuria that appears within 24 hours of the insulin withdrawal indicates a poor response to oral hypoglycemic drugs.
   4. Testing of the ketonuria is important In patients who have urine sugar positive and raised blood glucose.
   5. Ketonuria is done to differentiate between diabetic coma with positive ketones and insulin-shock negative ketonuria.
3. This is done by screening ketonuria, which is usually seen in hospitalized patients, children, pregnant women, and patients with diabetes.
4. During pregnancy, early detection of ketonuria is essential because ketoacidosis may lead to the fetus’s death.
5. It is done to judge the severity of the acidosis and the treatment response.
   1. Ketonuria may provide a more accurate indicator of acidosis than blood testing.
6. This is helpful in the emergency wards.

How will you define Ketone bodies?

• Increased ketone bodies in the blood are called Ketonemia.
• Increased excretion in the urine is called Ketonuria.

How will you discuss the pathophysiology of ketone bodies?

1. Fat metabolism, when completely metabolized, leads to CO2 and H2O formation. So, ketone bodies are not seen in the urine.
2. While intermediate products are ketone bodies.

What are the conditions where you will see Ketone bodies?

2. In the case of decreased availability of carbohydrates, like starvation or frequent vomiting.
3. Another possibility is decreased utilization of carbohydrates, such as diabetes mellitus and glycogen storage disease.
4. High-fat and low-carbohydrate diets are ketogenic and increase ketone bodies in the blood.
5. Ketones are the end product of fatty acid metabolism.

How will you explain Ketone bodies in diabetic patients?

1. Ketones are formed when glucose as a source of energy is not present.

2. This situation happens when there is no insulin, so glucose cannot enter the cells.
3. In that case, ketone bodies are the energy source for the body, particularly the brain.
4. In fasting for 3 to 4 days, the ketone bodies provide 30% to 40% of body energy.

5. Ketone bodies are the end product of fatty acid breakdown and consist of :
   1. Beta-hydroxybutyric acid.
   2. Acetoacetic acid.
   3. Acetone.

6. The β- hydroxybutyric acid + acetoacetic acid readily converts to acetone.
7. It shows that the main ketone is acetone to be tested.
8. Some of the kits only measure acetoacetic acid.

The ratio of ketone bodies

What are the types of ketone bodies?

1. Acetone is a minor amount.
2. Acetoacetate and β- hydroxybutyrate are equal in amount and are the main ketone bodies.
3. Ketones are formed in the liver and completely metabolized in a healthy person, but a negligible amount is in urine.

What is the outcome of increased Ketone levels in the blood?

1. Electrolyte imbalance.
2. Dehydration.
3. If not corrected, then it leads to acidosis, coma, and ultimately death.
4. Ketones are present in the urine when a threshold level exceeds the blood’s normal level.

What is the clinical significance of ketone bodies?

1. Insulin dosage for monitoring and managing insulin-dependent diabetes mellitus, type 1 diabetes.
2. Ketonuria shows insulin deficiency and needs to adjust the dose of insulin.
3. This is an early sign of an insufficient dose of insulin.
4. Diabetic acidosis (Inability to metabolize carbohydrates).
5. Vomiting (increased loss of carbohydrates).
6. Starvation (inadequate carbohydrate intake).
7. Malabsorption  (inadequate carbohydrate intake).
8. Pancreatic diseases.
9. Inborn error of amino acid metabolism.
10. Ketonuria shows a deficiency of insulin and indicates the regulation of insulin dose.
11. Strenuous exercise leads to ketonuria due to the overuse of carbohydrates.

What are the normal ketone bodies in urine?

• In Urine:
  • Ketone bodies are negative.
  • Small amount = <20 mg/dL.
  • Moderate amount = 30 to 40 mg/dL.
  • Large amount = >80 mg /dL.
• In blood or plasma:
  • Acetone = < 2.0 mg/dL (<0.34 mmol/L).
  • Acetoacetate = < 1 mg/dL (<0.1 mmol/L).
  • β-hydroxybutyric acid = 0.21 to 2.81 mg/dL (20 to 270 µmol/L).

Source 1

• Urine:
  • Acetoacetate = Negative.
  •  Acetone         = 0.3 mg/dL (0.05 mmol/L).
  • β-hydroxybutyric acid = Negative

Serum or plasma ketone bodies

• Acetone
  • Ketoacidosis = 10 to 70 mg/dL (1.72 to 12.04 mmol/L)
  • Occupational exposure = <10 mg/dL (<1.72 mmol/L)
  • Toxic concentration = >20 mg/dL  (>3.44 mmol/L)
• Acetoacetate    =   Negative  <1 mg/dL (<0.1 mmol/L)
• β-hydroxybutyric acid = 0.21 to 2.81 mg/dL (20 to 270 µmol/L)

How will you diagnose ketone bodies?

1. Various types of strips are available to detect the ketone bodies.

How will you explain Gerhardt’s Ferric chloride?

1. It reacts only with Acetoacetate.
2. This is an indirect method of detecting the β-hydroxybutyrate in the urine.
3. Nitroprusside has 10 times more sensitivity to acetoacetate than acetone.
   1. Acetoacetate (acetone) + sodium nitroprusside + glycine  →→  purple color
   2. There is no reaction with β- hydroxybutyrate.
4. It is reported as follows:
   1. Negative.
   2. Moderate.
   3. Large amount  OR as
   4. 1⁺, 2⁺, 3⁺.

How will you explain the Strip method for urine ketone bodies?

1. There are strips to detect β- hydroxybutyrate in the serum and urine are available.
2. Quantitative estimation of β- hydroxybutyrate in serum or blood kits is commercially available.

How will you compare various test strips for the detection of ketone bodies?

What are the causes of Ketone bodies?

1. Diabetic patients.
2. Starvation.
3. Fasting.
4. High protein diet.
5. Alcoholism.
6. Salicylates poisoning.
7. Isopropanol intake.
8. Acute febrile illness (especially in infants and children).
9. Renal Glycosuria.
10. Glycogen storage disease (Von Gierke’s disease).
11. Anorexia.
12. Low carbohydrate diet.
13. Pregnancy or lactation.
14. Eclampsia.
15. Fever.
16. Hyperthyroidism.
17. Prolonged vomiting and diarrhea.
18. Patients in the hospital may have ketonuria—roughly 15% show ketonuria in hospitalized patients without diabetes.
19. Ketonuria may develop after anesthesia with ether and chloroform.
20. Children are more prone to develop ketonuria and ketosis.

What is the critical value of ketonuria?

1. When ketonuria is positive, clinical action should be taken, and don’t take it lightly.
2. Ketonuria positive in infants <2 years of age is a serious and critical alert.
3. In diabetic patients, ketonuria positive means that diabetes is uncontrolled.
4. In non-diabetics, it suggests increased Fat intake and fewer carbohydrates.

Questions and answers: