From the Guidelines
Alcoholic ketoacidosis (AKA) and metabolic acidosis are primarily caused by the accumulation of lactic acid and ketoacids due to excessive alcohol consumption, altered NAD+/NADH ratio, and prolonged fasting and dehydration. The symptoms of AKA and metabolic acidosis include nausea, vomiting, abdominal pain, and altered mental status, which can progress to life-threatening complications if left untreated 1. Key factors contributing to the development of AKA and metabolic acidosis in alcoholics include:
- Altered NAD+/NADH ratio from alcohol metabolism
- Prolonged fasting and dehydration
- Electrolyte imbalances, particularly potassium, magnesium, and phosphate deficiencies
- Hypoglycemia due to impaired gluconeogenesis
Treatment of AKA and metabolic acidosis involves:
- Immediate cessation of alcohol intake
- Intravenous fluid resuscitation with normal saline
- Thiamine administration to prevent Wernicke's encephalopathy
- Correction of electrolyte imbalances
- Glucose supplementation if hypoglycemic
- Monitoring for complications, including withdrawal symptoms and hypoglycemia It is essential to address the underlying alcohol use disorder through appropriate referrals for substance abuse treatment to prevent recurrence, as alcohol abstinence is the cornerstone of therapy and the main determinant of long-term prognosis 1.
From the Research
Causes of Alcoholic Ketoacidosis (AKA) and Metabolic Acidosis
- Alcoholic ketoacidosis (AKA) is a common reversible biochemical pathology arising from hyperketonaemia in patients with a history of chronic alcohol consumption 2
- AKA is typically caused by a combination of factors including malnutrition, starvation, and dehydration, which lead to hyperketonaemia, hypovolaemia, and high anion gap metabolic acidosis (HAGMA) 2, 3
- Metabolic acidosis in alcoholics can also be caused by lactic acidosis, ketoacidosis, and acetic acidosis, with the degree of each varying from patient to patient 3
- Alcohol-induced acidosis is a mixed acid-base disturbance, with metabolic acidosis and metabolic alkalosis present simultaneously 3
Symptoms of Alcoholic Ketoacidosis (AKA) and Metabolic Acidosis
- The symptoms of AKA are non-specific, including abdominal pain, nausea, vomiting, and diarrhoea 2
- Vomiting and diarrhoea can lead to malnutrition and starvation, which subsequently lead to hyperketonaemia, hypovolaemia, and HAGMA 2
- Patients with AKA may present with severe HAGMA, hyperketonaemia, and dysglycaemia, which can be mistaken for diabetic ketoacidosis (DKA) 2, 4
Diagnosis and Management of Alcoholic Ketoacidosis (AKA) and Metabolic Acidosis
- A precise patient medical history is crucial to prevent misdiagnosis of AKA 2
- The mainstay of management of AKA is thiamine, fluid resuscitation, and good sugar control to prevent Wernicke's encephalopathy 2
- Treatment of alcohol acidosis should include sodium, chloride, potassium, phosphorus, magnesium, and thiamine replacements, along with attention to concomitant clinical problems 3
- Insulin should be withheld unless life-threatening acidemia is present or expected, and glucose need not be given immediately unless hypoglycemia is present 3