From the Guidelines
Ketones are a key feature of diabetic ketoacidosis (DKA), and their presence is crucial for the diagnosis and management of this condition. DKA is characterized by the excessive production of ketone bodies (acetoacetate, beta-hydroxybutyrate, and acetone) that occurs when the body cannot use glucose for energy due to insulin deficiency or insulin resistance, forcing it to break down fat for fuel instead [ 1 ]. This process leads to the accumulation of acidic ketones in the blood, causing metabolic acidosis.
Key Points to Consider
- The diagnostic criteria for DKA typically include elevated blood glucose (usually >250 mg/dL), the presence of ketones in blood or urine, and metabolic acidosis with a pH less than 7.3 and bicarbonate less than 18 mEq/L [ 1 ].
- Healthcare providers test for ketones using urine dipsticks or blood ketone meters, with blood ketone measurements being more accurate [ 1 ].
- Specific measurement of b-hydroxybutyrate in blood should be used for diagnosis of DKA and may be used for monitoring during treatment of DKA [ 1 ].
- Treatment focuses on insulin administration to stop ketone production, fluid replacement, and electrolyte correction, particularly potassium [ 1 ].
Importance of Ketone Measurement
Understanding the central role of ketones in DKA is essential for proper diagnosis and management of this serious diabetic complication. The presence of ketones is a critical indicator of the severity of DKA, and their measurement helps guide treatment decisions [ 1 ].
Clinical Implications
In clinical practice, it is crucial to prioritize the measurement of ketones in patients with suspected DKA, as it directly impacts treatment outcomes and patient morbidity, mortality, and quality of life [ 1 ]. By recognizing the importance of ketones in DKA, healthcare providers can deliver more effective and targeted care, ultimately improving patient outcomes.
From the Research
Ketones in Diabetic Ketoacidosis (DKA)
- Ketones are a key feature of diabetic ketoacidosis (DKA), as they are produced by the liver in response to low insulin levels and high levels of counterregulatory hormones 2.
- The two main ketone bodies are acetoacetate (AcAc) and 3-beta-hydroxybutyrate (3HB), while acetone is the third, and least abundant, ketone body 2.
- In DKA, high levels of ketones are produced, and the ketone body ratio (3HB:AcAc) rises from normal (1:1) to as high as 10:1 2.
- Serum ketone body levels can be useful in the diagnosis of DKA, with optimal cut-off values for diagnosis determined at 6.3 mmol/l of beta-hydroxybutyrate, 1.4 mmol/l of acetoacetate, and 8.0 mmol/l of total ketone body 3.
- Monitoring ketone levels is an essential part of acute illness management and for both early detection and prevention of a DKA episode, particularly in patients treated with sodium glucose cotransporter 2 inhibitor (SGLT2i) medications 4.
Importance of Ketone Monitoring
- Self-monitoring of ketone bodies by diabetes patients can be done using blood or urine, and both methods are clinically reliable 5.
- Ketone monitoring is particularly important for patients treated with SGLT2i medications, in which DKA can present with only moderately elevated glucose levels, referred to as euglycemic DKA (euDKA) 4.
- Education of patients and their social environment to promote frequent testing, especially during sick days, and to recognize the early symptoms of hyperglycemia and DKA is of paramount importance in preventing the development of severe DKA 5.
Diagnosis and Treatment
- DKA is diagnosed by the presence of hyperglycemia, metabolic acidosis, and ketosis, and serum ketone body levels can be used to differentiate between type 1 and type 2 diabetes mellitus 3.
- Treatment of DKA involves insulin therapy, fluid replacement, and electrolyte management, and monitoring ketone levels can help guide treatment decisions 2.
- Euglycemic DKA is a rare but potentially life-threatening condition that can be precipitated by SGLT2 inhibitors, and prompt diagnosis and treatment are essential to prevent morbidity and mortality 6.